lateral pterygoid to enter the deep surface of temporalis. The anterior and forwards on the surface of medial pterygoid (see Fig. 32.23), and
nerve frequently arises as a branch of the buccal nerve. The small pos- is thus carried progressively closer to the medial surface of the man-
terior nerve sometimes arises in common with the nerve to masseter. dibular ramus. It becomes intimately related to the bone a few milli-
metres below and behind the junction of the vertical ramus and
nerve to lateral pterygoid
horizontal body of the mandible. Here it lies anterior to, and slightly
The nerve to lateral pterygoid enters the deep surface of the muscle. It
deeper than, the inferior alveolar (dental) nerve. It next passes below
may arise separately from the anterior division of the mandibular nerve
the mandibular attachment of the superior pharyngeal constrictor and
or from the buccal nerve.
pterygomandibular raphe, closely applied to the periosteum of the
Posterior trunk of mandibular nerve medial surface of the mandible, until it lies opposite the posterior root
of the third molar tooth, where it is covered only by the gingival muco-
The posterior trunk of the mandibular nerve is larger than the anterior
periosteum. At this point, it usually lies approximately 3 mm below the
and is mainly sensory, although it receives fibres from the motor root
alveolar crest with a mean distance from the bone of 2 mm. Signifi-
for the nerve to mylohyoid. It divides into auriculotemporal, lingual
cantly, in more than 25% of cases, the nerve may be in direct contact
and inferior alveolar (dental) nerves (see Fig. 32.20A).
with the bone at this site, but sometimes it lies above the alveolar crest.
Auriculotemporal nerve It next passes medial to the mandibular origin of mylohyoid, and this
carries it progressively away from the mandible, and separates it from
The auriculotemporal nerve usually has two roots that encircle the
the alveolar bone covering the mesial root of the third molar tooth
middle meningeal artery. It runs back under lateral pterygoid on the


(Pogrel et al 1995). The rest of the nerve is described with the mouth
surface of tensor veli palatini, passes between the sphenomandibular
and oral cavity on page 514.
ligament and the neck of the mandible, and then runs laterally behind
the temporomandibular joint related to the upper part of the parotid
gland. Emerging from behind the joint, it ascends over the posterior Inferior alveolar (dental) nerve
root of the zygoma, posterior to the superficial temporal vessels, and The inferior alveolar nerve descends behind lateral pterygoid. At the
divides into superficial temporal branches. It communicates with the lower border of the muscle, the nerve passes between the sphenoman-
facial nerve and otic ganglion. The rami to the facial nerve, usually two, dibular ligament and the mandibular ramus, and enters the mandibular
pass anterolaterally behind the neck of the mandible to join the facial canal via the mandibular foramen (Barker and Davies 1972). Below
nerve at the posterior border of masseter. Filaments from the otic gan- lateral pterygoid, it is accompanied by the inferior alveolar artery (see
glion join the roots of the auriculotemporal nerve close to their origin. Fig. 32.23), a branch of the first part of the maxillary artery, which also
The sensory distribution of the auriculotemporal nerve on the face is enters the canal with associated veins. The subsequent course of the
described on page 502. inferior alveolar nerve is described on page 527.


Infratemporal and pterygopalatine fossae and temporomandibular joint
551.e1
23
RETPAHC
The anterior deep temporal nerve may arise from the buccal nerve,
and the posterior deep temporal nerve may arise from the nerve to
masseter. In addition, branches from the buccal and masseteric nerves
may supply the inferior aspect of the muscle independently from the
deep temporal nerves. Discrete neuromuscular subunits have been iden-
tified within the muscle based on the anterior, middle and posterior
deep temporal nerves, suggesting the possibility of individual dynamic
muscle flaps, each with a different vector, in the treatment of facial palsy
(Chang et al 2013) (Fig. 32.24).
3
2 4
5
1
V3
Fig. 32.24 The foramen ovale, inferolateral view. Nerves supplying
temporalis originate from the anterior trunk of the mandibular division of
the trigeminal nerve V3 (arrow). Key: 1, (long) buccal nerve; 2, anterior
deep temporal nerve; 3, middle deep temporal nerve; 4, posterior deep
temporal nerve; 5, nerve to masseter. (Courtesy of David Cantelmi,
University of Toronto, Canada. With permission from Chang Y, Cantelmi
D, Wisco J, et al. Evidence for the functional compartmentalization of the
temporalis muscle: a 3-dimensional study of innervation. J Oral Maxillofac
Surg 2013;71:1170–1177.)


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Neural anastomoses with the spread of infection between neighbouring tissue spaces from the
the mandibular nerve pterygomandibular space. When the submandibular, sublingual and
submental areas are affected either unilaterally or bilaterally (bilateral
involvement is known as Ludwig’s angina), there is a risk that the airway
Available with the Gray’s Anatomy e-book
may become obstructed. Infection may (potentially) spread further,
usually to the parapharyngeal, and occasionally to the retropharyngeal,
Otic ganglion spaces or the tissue planes of the face above, when it may even reach
the orbit via the inferior orbital fissure. Life-threatening cavernous sinus
The otic ganglion is a small (major diameter 3–4 mm), oval, flat thrombosis is a remote possibility once infection has spread to the
reddish-grey ganglion situated just below the foramen ovale. It is a orbit, with further spread directly through the superior orbital fissure
peripheral parasympathetic ganglion related topographically to the into the cranial cavity. Infection may also spread to the cavernous sinus
mandibular nerve but connected functionally with the glossopharyn- from the pterygoid plexus and ophthalmic veins (Smyth 2007, Guidera
geal nerve (see Fig. 37.13). Near its junction with the trigeminal motor et al 2014) (Fig. 32.26).
root, the mandibular nerve lies lateral to the ganglion; tensor veli pal-
atini lies medially, separating the ganglion from the cartilaginous part PTERYGOPALATINE FOSSA
of the pharyngotympanic tube, and the middle meningeal artery is
posterior to the ganglion. The otic ganglion usually surrounds the
origin of the nerve to medial pterygoid. The pterygopalatine fossa is a small pyramidal space below the apex of
Like all parasympathetic ganglia, there are three roots: motor, sym- the orbit on the lateral side of the skull. Placed between the infratem-


pathetic and sensory. Only the parasympathetic fibres relay in the gan- poral fossa laterally and the nasopharynx medially, it functions as a
glion (see Fig. 26.7). The motor, parasympathetic, root of the otic neurovascular conduit. The body of the sphenoid forms the roof, the
ganglion is the lesser petrosal nerve, conveying preganglionic fibres posterior boundary is the root of the pterygoid process and adjoining
from the glossopharyngeal nerve, which originate from neurones in the anterior surface of the greater wing of the sphenoid, and the anterior
inferior salivatory nucleus. The lesser petrosal nerve runs intracranially boundary is the superomedial part of the infratemporal surface (pos-
in the middle cranial fossa on the anterior surface of the petrous bone terior wall) of the maxilla. The perpendicular plate of the palatine bone,
before passing through either the foramen ovale or the sphenopetrosal with its orbital and sphenoidal processes, forms the medial boundary,
fissure or the innominate canal of Arnold (a canal in the greater wing and the pterygomaxillary fissure is the lateral boundary. There are two
of the sphenoid close to the foramen spinosum), to join the otic gan- openings in the posterior wall of the pterygopalatine fossa: the foramen
glion. The nerve synapses in the otic ganglion, and postganglionic fibres rotundum, which transmits the maxillary nerve, and the pterygoid canal
pass by a communicating branch to the auriculotemporal nerve and so (Vidian canal), which transmits the nerve of the pterygoid canal (Vidian
to the parotid gland. The sympathetic root arises from a plexus on the nerve). When the anterior aspect of the pterygoid plate is examined in
middle meningeal artery. It contains postganglionic fibres from the a disarticulated sphenoid, the foramen rotundum is seen to lie above
superior cervical sympathetic ganglion, which traverse the otic ganglion and lateral to the pterygoid canal (see Figs 32.3A, B).


without relay and emerge with parasympathetic fibres in the connection The fossa communicates with the nasal cavity via the sphenopalatine
with the auriculotemporal nerve to supply blood vessels in the parotid foramen; with the orbit via the medial end of the inferior orbital fissure;
gland. The sensory fibres from the gland are derived from the auriculo- and with the infratemporal fossa via the pterygomaxillary fissure, which
temporal nerve. Clinical observations suggest that in humans the gland lies between the back of the maxilla and the pterygoid process of the
also receives secretomotor fibres through the chorda tympani. sphenoid and transmits the maxillary artery. It also communicates with
the middle fossa via foramen rotundum and the pterygoid canal, and
branches with the oral cavity via the greater palatine canal, which opens in the
posterolateral aspect of the hard palate. Its proximity to these adjacent
A branch connects the otic ganglion to the chorda tympani nerve, while
areas permits the ready spread of both tumours and infection.
another ramus ascends to join the nerve of the pterygoid canal. These
The main contents of the pterygopalatine fossa are the third part
branches may form an additional pathway by which gustatory fibres
of the maxillary artery, the maxillary nerve and many of its branches,
from the anterior two-thirds of the tongue may reach the facial ganglion
and the pterygopalatine ganglion.
without traversing the middle ear, and they do not synapse in the otic
ganglion. Motor branches to tensor veli palatini and tensor tympani,
Maxillary artery
derived from the nerve to medial pterygoid, also pass through the gan-
glion without synapsing. (For further reading, see Senger et al (2014).)
The maxillary artery passes through the pterygomaxillary fissure from
Chorda tympani the infratemporal fossa into the pterygopalatine fossa, where it termin-
ates as the third part of the maxillary artery. The artery has a variable
and tortuous course in its short passage through the pterygopalatine
The chorda tympani nerve enters the infratemporal fossa region by


fossa, where it gives off numerous branches, including the posterior
passing through the medial end of the petrotympanic fissure behind
superior alveolar and infraorbital arteries and the artery of the pterygoid
the capsule of the temporomandibular joint. The nerve descends medial
canal (Vidian artery), and terminates in the sphenopalatine and greater
to the spine of the sphenoid bone – which it sometimes grooves – lying
palatine arteries.
posterolateral to tensor veli palatini. It is crossed medially by the middle
meningeal artery, the roots of the auriculotemporal nerve and by the Posterior superior alveolar artery
inferior alveolar nerve (see Fig. 32.23). The chorda tympani joins the
The posterior superior alveolar artery arises from the maxillary artery
posterior aspect of the lingual nerve at an acute angle. It carries taste
within the pterygopalatine fossa and runs through the pterygomaxillary
fibres for the anterior two-thirds of the tongue and efferent pregangli-
fissure on to the maxillary tuberosity. It gives off branches that penetrate
onic parasympathetic (secretomotor) fibres destined for the sub-
the bone here to supply the maxillary molar and premolar teeth and
mandibular ganglion in the floor of the mouth.
the maxillary air sinus, and other branches that supply the buccal
mucosa. Occasionally, the posterior superior alveolar artery arises from
the infraorbital artery.
SPREAD OF INFECTION FROM
THE INFRATEMPORAL FOSSA Infraorbital artery
The infraorbital artery enters the orbit through the inferior orbital
Infections from most teeth in the upper jaw or the front of the lower fissure. It runs on the floor of the orbit in the infraorbital groove and
jaw usually drain harmlessly into the oral cavity, either via the vestibule infraorbital canal, and emerges on to the face at the infraorbital foramen
buccally, or via the palate or mouth lingually. In contrast, a pericoronitis to supply the lower eyelid, part of the cheek, the side of the external
that affects a mandibular third molar tooth that communicates with nose, and the upper lip. While within the infraorbital canal, it gives off


the oral cavity, or, less commonly, either a dental abscess associated the anterior superior alveolar artery, which runs downwards to supply
with this tooth, or a postoperative infection, may spread along tissue the anterior teeth and the anterior part of the maxillary sinus. A middle
planes. Spread may be buccal; submandibular; submental; parapharyn- superior alveolar artery is also often described. When present, it
geal; sublingual; less commonly, submasseteric; and, more rarely, branches from the infraorbital artery within the infraorbital canal and
infratemporal. The main symptom caused by infection of the pterygo- runs inferiorly along the lateral wall of the maxillary sinus towards the
mandibular region is trismus (painful reflex muscle spasm), which region of the canine and lateral incisor teeth, anastomosing with the
usually affects medial pterygoid. There are few anatomical barriers to anterior and posterior superior alveolar arteries.


Infratemporal and pterygopalatine fossae and temporomandibular joint
552.e1
23
RETPAHC
Extensive anastomoses, which may be sensory-to-sensory, sensory-to-
motor or motor-to-motor, exist between the lower cranial nerves and
upper cervical nerves. Variable anastomoses exist between all three of
the divisions of the trigeminal nerve with branches of the facial nerve.
The connection between the lingual nerve and the chorda tympani
branch of the facial is the most familiar interconnection with the man-
dibular nerve. Connections have almost always been demonstrated
between the auriculotemporal nerve and branches of the facial nerve
(Fig. 32.25). The buccal branch may communicate with the buccal and
zygomatic branches of the facial via the ‘communicating buccal nerve’.
Interconnections between the mental nerve and the buccal and mar-
ginal mandibular branch of the facial have been demonstrated. It is
suggested that one possible explanation for these trigeminal–facial
interconnections relates to the proprioceptive innervation of the facial
musculature. A branch from the auriculotemporal may join the inferior
alveolar nerve within the infratemporal fossa with evident implications
for referred pain. The functional significance of some of the neural con-
nections has yet to be determined (Shoja et al 2014).
A
Auriculotemporal nerve
Anastomosis between the
auriculotemporal nerve and
temporofacial division of the
facial nerve
Temporofacial division
of the facial nerve
Cervicofacial division of
the facial nerve
Facial nerve
Anastomosis between the great
auricular nerve and cervicofacial
division of the facial nerve B
Fig. 32.26 A, Ludwig’s angina: spread of infection from an infected lower
Great auricular nerve
left third molar to the pterygomandibular space and thence into the
submandibular, sublingual and submental spaces bilaterally. The infection
is life-threatening due to restricted mouth opening and a compromised
Fig. 32.25 Anastomoses of the auriculotemporal nerve with the airway. B, In this case, the airway was secured with awake fibreoptic


temporofacial division of the facial nerve, and of the great auricular nerve intubation followed by tracheostomy. Aggressive through-and-through
with the cervicofacial division of the facial nerve in the parotid and drainage was initiated (note the grey discolouration of the tissues). Prior
periparotid regions. (With permission from Shoja MM, Oyesiku NM, to the availability of antibiotics, Ludwig’s angina had a mortality rate of
Grissenauer CJ et al. Anastomoses between lower cranial and upper 75%. Aggressive early treatment with surgical drainage and intravenous
cervical nerves: a comprehensive review with potential significance during antibiotics has reduced the mortality to approximately 5%. The narrow
skull base and neck operations, Part 1: Trigeminal, facial and white arrow indicates the cut edge of mylohyoid. The broad white arrow
vestibulocochlear nerves. Clin Anat. 2014;27(1):118–30.) indicates through-and-through corrugated drains. (Smyth AG 2007
Management of orofacial infections. In: Ward-Booth P, Schendel SA,
Hausamen JE (eds) Maxillofacial Surgery, 2nd ed. Ch. 80, pp. 1550–71.)


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Some authors describe anterior and posterior ‘compartments’ of the
pterygopalatine fossa, where the anterior compartment contains the
third part of the maxillary artery and its branches, and the posterior
compartment contains the maxillary division of the trigeminal nerve
and the nerve of the pterygoid canal, together with the pterygopalatine
ganglion and its branches (Figs 32.27–32.28) (Alfieri et al 2003,
Cavallo et al 2005, Falcon et al 2010).
Fig. 32.27 An endoscopic view demonstrating the
Lateral Medial
Orbital floor Sphenoidal sinus anterior (vascular) compartment of the right
Infraorbital artery pterygopalatine fossa (00 lens endoscope). The
and nerve Maxillary nerve vascular structures are anterior to the neural
Deep temporal artery at foramen rotundum structures. Fat has been removed. (Image courtesy
and branches Pterygopalatine ganglion of Professor C Snyderman, University of
Pittsburgh Medical Center.)
Sphenopalatine artery
Inferior alveolar artery
Posterior superior alveolar
artery and nerve
Nasopharynx
Maxillary artery Greater palatine
artery and nerve
Lateral pterygoid plate
Fig. 32.28 An endoscopic view demonstrating the
Lateral Medial
posterior (neural) compartment of the right
pterygopalatine fossa (00 lens endoscope). The
Maxillary nerve exiting principal vascular structures and fat have been
foramen rotundum removed. (Image courtesy of Professor C
Snyderman, University of Pittsburgh Medical
Pterygopalatine Center.)
ganglion
(Vidian) nerve exiting
pterygoid (Vidian) canal


Pterygopalatine fossa
553
23
RETPAHC
Artery of the pterygoid canal The maxillary nerve gives off many of its branches in the pterygo-
palatine fossa. They can be subdivided into those that come directly from
The artery of the pterygoid canal (Vidian artery) usually arises as a
the nerve, and those that are associated with the pterygopalatine para-
branch of the distal part of the maxillary artery or sometimes as a
sympathetic ganglion. Named branches from the main trunk are menin-
branch of the petrous segment of the internal carotid artery. It passes
geal, ganglionic, zygomatic, posterior, middle and anterior superior
through the pterygoid canal and anastomoses with the pharyngeal,
alveolar and infraorbital nerves. Named branches from the pterygo-
ethmoidal and sphenopalatine arteries in the pterygopalatine fossa and
palatine ganglion are orbital, nasopalatine, posterior superior nasal,
with the ascending pharyngeal, accessory meningeal, ascending pala-
greater (anterior) palatine, lesser (posterior) palatine and pharyngeal.
tine and descending palatine arteries in the oropharynx and around
the pharyngotympanic tube. Through these complex anastomoses, the Meningeal nerve
artery of the pterygoid canal contributes to the supply of part of the
The meningeal branch of the maxillary nerve arises within the middle
pharyngotympanic tube, the tympanic cavity and the upper part of
cranial fossa and runs with the middle meningeal vessels. It contributes
the pharynx. It may also anastomose with the artery of the foramen
to the innervation of the dura mater.
rotundum and so communicate with branches of the cavernous portion
of the internal carotid artery. Ganglionic branches
There are usually two ganglionic branches that connect the maxillary
Pharyngeal artery
nerve to the pterygopalatine ganglion.
The pharyngeal branch of the maxillary artery passes through the pala-
tovaginal canal, accompanying the nerve of the same name, and is Zygomatic nerve


distributed to the mucosa of the nasal roof, nasopharynx, sphenoidal The zygomatic branch of the maxillary nerve leaves the pterygopalatine
air sinus and pharyngotympanic tube. fossa through the inferior orbital fissure together with the maxillary
nerve. Its subsequent course is described on page 502.
Greater (descending) palatine artery
Posterior superior alveolar nerve
The greater palatine artery leaves the pterygopalatine fossa through the
greater (anterior) palatine canal, within which it gives off two or three The posterior superior alveolar nerve leaves the maxillary nerve in the
lesser palatine arteries. The greater palatine artery supplies the inferior pterygopalatine fossa. Its subsequent course and distribution are
meatus of the nose, then passes on to the roof of the hard palate at the described on page 526.
greater (anterior) palatine foramen and runs forwards to supply the Infraorbital nerve
hard palate and the palatal gingivae of the maxillary teeth. It gives off
The infraorbital nerve can be regarded as the terminal branch of the
a branch that runs up into the incisive canal to anastomose with the
maxillary nerve. It leaves the pterygopalatine fossa to enter the orbit at
nasopalatine artery, and so contribute to the arterial supply of the nasal
the inferior orbital fissure, and its subsequent course and distribution
septum. The lesser palatine arteries emerge on to the palate through the
are described on page 502.
lesser (posterior) palatine foramen, or foramina, and supply the soft
palate. Orbital branches
Fine orbital branches enter the orbit through the inferior orbital fissure
Sphenopalatine artery
and supply orbital periosteum. Some fibres also pass through the pos-
The sphenopalatine artery and the greater palatine artery are the termi- terior ethmoidal foramen to supply the sphenoidal and ethmoidal
nal branches of the maxillary artery. The sphenopalatine artery is the sinuses. The orbital branches are believed to join branches of the intern-
principal artery supplying the mucosa of the nose. It enters the nasal al carotid nerve to form a ‘retro-orbital’ plexus, from which orbital


cavity through the sphenopalatine foramen posterior to the su perior structures such as the lacrimal gland and orbitalis receive an autonomic
meatus. From here, its posterior lateral nasal branches ramify over the innervation (Ruskell 2004).
conchae and meatuses, anastomosing with the ethmoidal arteries and
nasal branches of the greater palatine artery to supply the frontal, maxil- Nasopalatine nerve
lary, ethmoidal and sphenoidal air sinuses. The sphenopalatine artery The nasopalatine nerve leaves the pterygopalatine fossa through the
next crosses anteriorly on the inferior surface of the sphenoid and ends sphenopalatine foramen and enters the nasal cavity. It passes across the
on the nasal septum in a series of posterior septal branches that anas- cavity to the back of the nasal septum, runs downwards and forwards
tomose with the ethmoidal arteries (see Fig. 33.9). on the septum in a groove in the vomer, and then turns down through
the incisive fossa in the anterior part of the hard palate to enter the roof
Spatial arrangement of the neurovascular of the mouth (see Fig. 33.11). When an anterior and a posterior incisive
contents in the pterygopalatine fossa foramen exist in this fossa, the left nasopalatine nerve passes through
the anterior foramen, and the right nerve passes through the posterior
foramen. The nasopalatine nerve supplies the lower part of the nasal
The maxillary artery and its branches are located in a plane anterior to
septum and the anterior part of the hard palate, where it communicates
the maxillary nerve, pterygopalatine ganglion and the nerve of the
with the greater palatine nerve. The nasopalatine artery, a branch of the
pterygoid canal. This spatial arrangement is particularly relevant in
maxillary artery, accompanies the nasopalatine nerve, ending in the
endoscopic approaches to the pterygopalatine fossa (Video 32.2). The
incisive canal, where it anastomoses with greater palatine artery and the
veins accompanying the third (pterygopalatine) part of the maxillary
septal branch of the superior labial artery.


artery, in common with those accompanying the second (pterygoid)
part, are in the form of a venous plexus. Profuse haemorrhage may be Posterior superior nasal nerves
encountered from this pterygopalatine venous plexus. (lateral and medial)
The posterior superior alveolar nerves enter the back of the nasal cavity
Maxillary nerve
through the sphenopalatine foramen. Lateral posterior superior nasal
nerves (about six) innervate the mucosa lining the posterior part of the
The maxillary division of the trigeminal nerve is wholly sensory (Fig. superior and middle nasal conchae and the posterior ethmoidal sinuses.
32.30). It leaves the skull via the foramen rotundum and enters the Two or three medial posterior superior nasal nerves cross the nasal roof
upper part of the pterygopalatine fossa, from which all its extracranial below the opening of the sphenoidal sinus to supply the mucosa of the
branches are derived. The meningeal branch is given off in the middle posterior part of the roof and of the nasal septum.
fossa. Crossing the pterygopalatine fossa, the nerve gives off two large
Palatine nerves (greater and lesser)
ganglionic branches that contain fibres destined for the nose, palate and
pharynx, and these pass through the pterygopalatine ganglion without The greater and lesser palatine nerves pass downwards from the pterygo-
synapsing. It then inclines sharply laterally on the posterior surface of palatine ganglion through the greater palatine canal. The greater pala-
the orbital process of the palatine bone and on the upper part of the tine nerve descends through the greater palatine canal, emerges on the
posterior surface of the maxilla in the inferior orbital fissure (which is hard palate from the greater palatine foramen and runs forwards in a
continuous posteriorly with the pterygopalatine fossa); it lies outside groove on the inferior surface of the bony palate almost to the incisor
the orbital periosteum, and gives off its zygomatic and then posterior teeth. It supplies the gingivae, mucosa and glands of the hard palate
superior alveolar branches. About halfway between the orbital apex and and also communicates with the terminal filaments of the nasopalatine


the orbital rim, the maxillary nerve turns medially to enter the infra- nerve. In the greater palatine canal, it gives off posterior inferior nasal
orbital canal as the infraorbital nerve. The subsequent course of the branches that emerge through the perpendicular plate of the palatine
maxillary nerve is described on page 502. bone and ramify over the inferior nasal concha and walls of the middle


Infratemporal and pterygopalatine fossae and temporomandibular joint
553.e1
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RETPAHC
The internal carotid artery–external carotid artery communication
via the artery of the pterygoid canal is one of a number of collateral
vascular pathways that exist between the external carotid artery and
branches of the petrous and intracavernous segments of the internal
carotid artery. Albeit small and difficult to demonstrate angiograph-
ically, these vascular connections may nevertheless provide the arterial
supply for arteriovenous malformations, dural-based fistulae and skull
base tumours, and may also compensate for occlusion of the internal
carotid artery. They also pose a risk of inadvertent embolization of the
brain parenchyma during interventional angiography of the external
carotid artery system.
In view of the extensive communications between the artery of the
pterygoid canal and the highly vascular nasopharyngeal mucosa, for
example, embolization of the external carotid artery branches may
result in incomplete obliteration of a vascular nasopharyngeal lesion
when the artery of the pterygoid canal arises from the internal carotid
artery. Conversely, the collateral circulation provided by the artery of
the pterygoid canal may play a role in maintaining cerebral circulation
if there is stenosis of the petrous internal carotid artery proximal
to the point where the artery of the pterygoid canal joins it; the flow
in the post-stenotic segment of the internal carotid artery will be
supplemented from the external carotid artery via the artery of the
pterygoid canal (Fig. 32.29) (Tubbs et al 2007, Takeuchi et al 2005,
Allen et al 2005).
As the greater palatine artery runs the length of the hard palate, it
permits axial mucoperiosteal flaps to be raised, if necessary bilaterally,
for the reconstruction of local defects. It is also possible to pedicle the
entire mucoperiosteum of the hard palate on a single greater palatine
artery. The vascular supply to the denuded palatal bone is sufficient, Fig. 32.29 A right common carotid angiogram, left anterior oblique view.


presumably from its nasal surface, to permit regeneration of the palatal The ascending pharyngeal artery provides a collateral blood flow to the
soft tissue. Contracture of the regenerated tissue does not occur because petrous internal carotid artery via the artery of the pterygoid canal (arrow).
the defect lies over the palatal bone (Gullane and Arena 1977, Gullane (With permission from Takeuchi M, Kuwayama N, Kubo M, et al. Vidian
and Arena 1985, Salins and Benjamin 2009). artery as a collateral channel between the external and occluded internal
carotid arteries. Neuro Med Chir (Tokyo) 2005;45:470–471.)
Ligation of the sphenopalatine artery may be necessary in the control
of refractory epistaxis. It is usually located endoscopically at the
posterior/inferior end of the middle turbinate. Multiple branches may
be encountered. The sphenopalatine artery provides the axial blood
supply to the nasal septal mucosal flap (nasoseptal flap) used in endo-
scopic skull-base repair, a reflection of its contribution to the vascular
supply to the nasal cavity (Hadad et al 2006).


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A Infraorbital nerve Maxillary nerve Ophthalmic nerve
Zygomatic branch
Trigeminal nerve
Trigeminal ganglion
Mandibular nerve
Lingual nerve
Superior alveolar nerves
Inferior alveolar nerve
Mental nerve
Inferior dental plexus
B
Trigeminal ganglion Trigeminal nerve
Deep petrosal nerve (sympathetic root) Motor root of trigeminal
Mandibular nerve
Lesser petrosal nerve
Ophthalmic nerve
Greater petrosal nerve (parasympathetic root)
Geniculate ganglion Maxillary nerve
Optic nerve
Ganglionic branches
(sensory root)
Facial nerve
Infraorbital nerve
Vagus nerve
Glossopharyngeal nerve
Posterior superior
Internal carotid nerve
alveolar nerves
Internal carotid artery
Pterygopalatine ganglion
Nerve of pterygoid canal
Fig. 32.30 A, Maxillary and mandibular nerves. B, The nerves of the pterygoid canal and the pterygopalatine ganglion. The trigeminal ganglion has been
lifted forwards out of the trigeminal impression. Note the sympathetic plexus on the internal carotid artery. (With permission from Waschke J, Paulsen F
(eds), Sobotta Atlas of Human Anatomy, 15th ed, Elsevier, Urban & Fischer. Copyright 2013.)
and inferior meatuses. As it leaves the greater palatine canal, it gives off Pharyngeal nerve
branches that are distributed to both surfaces of the adjacent part of the
The pharyngeal branch of the maxillary nerve leaves the pterygopalatine
soft palate (see Fig. 31.3).
ganglion posteriorly. It passes through the palatovaginal canal with the
The lesser (middle and posterior) palatine nerves are much smaller
pharyngeal branch of the maxillary artery and supplies the mucosa of
than the greater palatine nerve. They descend through the greater pala-
the nasopharynx behind the pharyngotympanic tube.
tine canal, from which they diverge low down to emerge through the


lesser palatine foramina in the tubercle or pyramidal process of the Neural anastomoses with the maxillary nerve
palatine bone. They innervate the uvula, tonsil and soft palate.
Fibres conveying taste impulses from the palate probably pass via Available with the Gray’s Anatomy e-book
the palatine nerves to the pterygopalatine ganglion. They pass through
the ganglion without synapsing and leave via the greater petrosal
Pterygopalatine ganglion
nerve. Their cell bodies are located in the facial ganglion and their
central processes pass via the sensory root of the facial nerve (nervus
intermedius) to the gustatory nucleus in the nucleus of the tractus The pterygopalatine ganglion, the largest of the peripheral parasympa-
solitarius. thetic ganglia, is well protected, deep in the pterygopalatine fossa.


Infratemporal and pterygopalatine fossae and temporomandibular joint
554.e1
23
RETPAHC
Extensive anastomoses, which may be sensory-to-sensory, sensory-to-
motor or motor-to-motor, exist between the lower cranial nerves and
upper cervical nerves. Variable anastomoses exist between all three of
the divisions of the trigeminal nerve with branches of the facial nerve.
The majority of trigeminal nerve interconnections are with the facial
nerve. Connections between the zygomaticotemporal branch of the
maxillary nerve and the temporal branches of the facial nerve, and the
zygomaticofacial branch of the maxillary nerve and the zygomatic
branches of the facial nerve have been demonstrated (Shoja et al 2014).
The connection between the zygomaticotemporal and lacrimal nerves
in the orbit providing parasympathetic secretomotor fibres to the lac-
rimal gland, as was once thought, is less certain. It is more likely that
the postganglionic orbital branches pass through the inferior orbital
fissure and innervate the lacrimal gland directly (Ruskell 2004). It has
been suggested that one possible explanation for these trigeminal–facial
interconnections relates to the proprioceptive innervation of the facial
musculature but the functional significance of some of the neural con-
nections has yet to be determined.


555
23
RETPAHC
Key references
Immediately anterior to the pterygoid canal, the ganglion lies below zygomaticotemporal branches of the maxillary nerve to the lacrimal
and medial to the foramen rotundum and the maxillary nerve, and gland, but most are thought to travel by orbital branches to the gland
lateral to the sphenopalatine foramen (see Fig. 32.30B). It is flattened (see above). The parasympathetic supply to the pre-ocular part of the
and reddish-grey in colour, and lies just below the maxillary nerve as it central artery of the retina is believed to be derived mainly from the
crosses the pterygopalatine fossa. The majority of the ‘branches’ of pterygopalatine ganglion and is vasodilatory (Ch. 42). Preganglionic
the ganglion are connected with it morphologically but not function- secretomotor fibres of uncertain origin also travel in the nerve of the
ally, because they are primarily sensory branches of the maxillary nerve. pterygoid canal. They synapse in the pterygopalatine ganglion, and
Thus they pass through the ganglion without synapsing and enter the postganglionic fibres are distributed to palatine, pharyngeal and nasal
maxillary nerve through its ganglionic branches; they convey some mucous glands via palatine and nasal branches of the maxillary nerve.
parasympathetic fibres to the palatine, pharyngeal and nasal mucous Postganglionic sympathetic fibres pass through the ganglion without
glands. synapsing and supply blood vessels and orbitalis. They arise in the
Preganglionic parasympathetic fibres destined for the pterygopala- superior cervical ganglion and travel via the internal carotid plexus and
tine ganglion run initially in the greater petrosal branch of the facial deep petrosal nerve to enter the pterygopalatine ganglion within the
nerve, and then in the nerve of the pterygoid canal (Vidian nerve), after nerve of the pterygoid canal.
the greater petrosal unites with the deep petrosal nerve. The nerve of General sensory fibres destined for distribution via orbital, nasopala-


the pterygoid canal enters the ganglion posteriorly. Postganglionic para- tine, superior alveolar, palatine and pharyngeal branches of the maxil-
sympathetic fibres leave the ganglion; some may join the maxillary lary division of the trigeminal nerve run through the ganglion without
nerve via a ganglionic branch and then travel via the zygomatic and synapsing.
Bonus e-book images and videos
Fig. 32.2 The ‘extended’ infratemporal Fig. 32.12 A transverse section at the level Fig. 32.27 An endoscopic view
fossa. of the hard palate demonstrating the cranial demonstrating the anterior (vascular)
fascia and associated compartments. compartment of the right pterygopalatine
Fig. 32.4 The stylohamular plane. fossa (00 lens endoscope).
Fig. 32.19 The arterial network of the human
Fig. 32.8 The opposing direction of temporalis muscle. Fig. 32.28 An endoscopic view
resorption (‘atrophy’) of the mandible and demonstrating the posterior (neural)
maxilla, resulting in increasing incongruity Fig. 32.24 The foramen ovale, inferolateral compartment of the right pterygopalatine
between the jaws. view. fossa (00 lens endoscope).
Fig. 32.9 A bilateral fracture of an Fig. 32.25 Anastomoses of the Fig. 32.29 A right common carotid
edentulous atrophic mandible. auriculotemporal nerve with the angiogram, left anterior oblique view.
temporofacial division of the facial nerve,
Fig. 32.10 A CT image showing the lateral and of the great auricular nerve with the Video 32.1 Temporomandibular joint
lingual foramina. cervicofacial division of the facial nerve in arthroscopy demonstrating intracapsular
the parotid and periparotid regions. anatomy of the joint.
Fig. 32.11 A three-dimensional reformatted
CT image showing an implant perforating Fig. 32.26 Ludwig’s angina: spread of Video 32.2 Endoscopic anatomy of the
the lingual cortical plate, leading to infection from an infected lower left third infratemporal and pterygopalatine fossae.


haemorrhage in the anterior floor of the molar to the pterygomandibular space and
mouth. thence into the submandibular, sublingual
and submental spaces bilaterally.
KEY REFERENCES
Barker BCW, Davies PL 1972 The applied anatomy of the pterygomandibu- Juniper RP 1981 The superior pterygoid muscle. Br J Oral Surg 19:121–8.
lar space. Br J Surg 10:43–55. An electromyographic study in human subjects demonstrating that the
A description of the relationships of the structures within the superior and inferior heads of the lateral pterygoid have opposing
pterygomandibular space, with particular reference to anaesthesia associated (antagonistic) action. The superior head is active during closure –
with an inferior alveolar nerve block. particularly the terminal closing phase and on clenching, stabilizing the
condyle against the articular eminence.
Cavallo LM, Messina A, Gardner P et al 2005 Extended endoscopic endo-
nasal approach to the pterygopalatine fossa: anatomical study and clini- Lang J 1995 Mandible. In: Clinical Anatomy of the Masticatory Apparatus
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bony landmarks and contents, when approached endoscopically. and mandible, the infratemporal fossa and its contents, and the
temporomandibular joint, relating these to clinical practice.
Cawood J, Howell RA 1988 A classification of the edentulous jaws. Int J Oral
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possible role in disc displacement.
Cheung LK 1996 The vascular anatomy of the human temporalis muscle:
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A cadaveric study of 15 cadavers/30 temporalis muscle specimens to assess A review of the literature on the blood supply of the anterior mandible
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(angiosomes) and the clinical implications of the results. lateral lingual foramina; its relevance to clinicians is discussed.
Guidera AK, Dawes PJD, Fong A et al 2014 Head and neck fascia and com- Stegenga B, de Bont LGM 2006 TMJ disc derangements. In: Laskin DM,
partments: no space for spaces. Head Neck 36:1058–68. Greene CS, Hylander WL (eds) TMDs: An Evidence-Based Approach to
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Surg 64:334–8.


CHAPTER
33
Nose, nasal cavity and paranasal sinuses
Box 33.1 A note on terminology
Sphenoidal
‘The advent of endoscopic sinus surgery led to a resurgence of sinuses
interest in the detailed anatomy of the internal nose and paranasal
sinuses. However, the official Terminologia Anatomica used by basic Frontal sinuses
anatomists omits many of the structures of surgical importance.
This led to numerous clinical anatomy papers and much discussion Ethmoidal air cells
about the exact names and definitions for the structures of surgical Orbit
relevance. The European position paper on the anatomical
terminology of the internal nose and paranasal sinuses was
conceived to re-evaluate the anatomical terms in common usage by
endoscopic sinus surgeons and to compare this with the official
Terminologia Anatomica’ (Lund et al 2014). Nasolacrimal duct
Where appropriate, the terms used in this chapter are those
commonly used in surgical practice as set out in the ‘European
position paper on the anatomical terminology of the internal nose
and paranasal sinuses’ (Table 33.1). Conflicts inevitably arise but
hopefully have been minimized. The terms ‘concha’ and ‘turbinate’
are often used interchangeably but anatomists rarely use the latter
term, while clinicians rarely use the former; in this chapter, concha
is used to describe the bony structure seen in dried skulls, while
turbinate is used to describe the bony structures, together with their
Maxillary sinuses
overlying soft tissue and mucosa, that are encountered during
surgery. ‘Ethmoturbinal’ does not appear in Terminologia Anatomica Fig. 33.1 An overview of the spatial relationships between the nasal
but is the collective term for the superior and middle turbinates, cavity, paranasal sinuses and nasolacrimal ducts. (From Drake RL, Vogl
AW, Mitchell A (eds), Gray’s Anatomy for Students, 2nd ed, Elsevier,
occasionally supplemented by a supreme turbinate. With regard to
Churchill Livingstone. Copyright 2010.)
the terms ‘skull base’ and ‘cranial base’, although they are
frequently used as though synonymous (the term ‘skull base’ is
favoured in the position paper), the anterior skull base includes the


inferior surface of the facial skeleton and will therefore be
continuous with the forehead, and its free tip forms the apex, which
distinguished from the anterior cranial base, which is delimited by
projects anteriorly. The overall shape of the external nose is very variable.
the inner and outer surfaces of the anterior cranial fossa (Ch. 27).
The lateral surfaces of the nose unite in the median plane to form the
dorsum, which is narrowest at the medial canthus. The lobule is an area
containing the tip of the nose. Its base contains two ellipsoidal aper-
tures, the external nares or nostrils, which open on to its inferior surface,
Box 33.1 and Table 33.1 present a note on terminology relating to the
separated by the nasal septum and columella. The columella usually
structures described in this chapter.
projects below the alar margin. The alar sulcus is a groove in the skin
bounding the nasal alae above and joining the nasiolabial sulcus. Below,
NOSE it curves towards the tip of the nose but does not reach it.
The nose is the first part of the upper respiratory tract and is responsible FACIAL AND NASAL PROPORTIONS
for warming, humidifying and, to some extent, filtering inspired air. It
also houses the olfactory epithelium, which contains olfactory receptor
neurones responsible for detecting airborne odorant molecules. Available with the Gray’s Anatomy e-book
The nose may be subdivided into an external nose, which opens
anteriorly on to the face through the nostrils or nares, and an internal
chamber, divided sagittally by a septum into right and left cavities, SKIN AND SOFT TISSUE
which open posteriorly into the nasopharynx through the posterior
nasal apertures or choanae. The nasal cavities are housed in a support- The skin and soft tissue covering the nose vary in thickness. They are
ing framework composed of bone and fibroelastic cartilages. The larger usually thin over the dorsum in the mid third, especially at the osseo-
bones in this framework contain air-filled spaces lined with respiratory cartilaginous junction, the rhinion, and loosely connected to the nasal


epithelium, described collectively as the paranasal sinuses. The sinuses aponeurosis and the muscle fibres that fan out within it. It is thicker
and the nasolacrimal ducts drain into the nasal cavity via openings in over the nasofrontal angle, and at the tip, where it has numerous large
its lateral walls (Fig. 33.1). sebaceous glands and is more adherent. These variations affect the final
nasal contour and profile after rhinoplasty.
The skin of the nose is separated from the underlying osteocartilagi-
EXTERNAL NOSE
nous framework by four layers. These are the superficial fatty pannicu-
lus; the fibromuscular layer, a continuation of the facial superficial
The external nose is a pyramidal structure located in the midline of the musculo-aponeurotic system (SMAS) (see chapter 30); the deep fatty
556 midface and attached to the facial skeleton. Its upper angle or root is layer; and the periosteum or perichondrium.


Nose, nasal cavity and paranasal sinuses
556.e1
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Table 33.1 Terminology
Present ‘surgical’ Rhinological and anatomical synonyms Terminologia Anatomica Suggested English Frequency of variant
terminology (textbooks, literature) terminology (position paper) in literature*
1 Nasal cavity Inner nose Cavitas nasi Nasal cavity
Cavum nasi
1.1 Lateral nasal wall Lateral nasal wall n.e. Lateral nasal wall
1.2 Floor of nasal cavity Nasal floor n.e. Nasal floor
1.3 Nasal septum Septum nasi Septum nasi Nasal septum
1.3.1 Cartilaginous portion Cartilaginous part of the nasal septum Pars cartilaginea (septi nasi) Septal cartilage
Cartilaginous segment Cartilago septi nasi
Septal cartilage
Lamina quadrangularis
1.3.2 Bony part Bony/osseous septum Pars ossea septi nasi Bony septum
Bony/osseous part of the nasal septum
1.3.2.1 Lamina perpendicularis Perpendicular plate of ethmoid Lamina perpendicularis ossis Perpendicular plate of ethmoid
ethmoidalis
1.3.2.2 Vomer Vomer Pars ossea septi nasi Vomer
1.3.3 Membranous portion Membranous portion Pars membranacea septi nasi Membranous portion (of nasal
septum)
1.3.4 Jacobson’s organ Vomero-nasal organ Organum vomeronasale Vomero-nasal organ
1.3.5 Septal tubercle Tuberculum septi nasi n.e. Septal tubercle
Zuckerkandl’s tubercle
Morgagni’s tubercle
Septal swell body
1.4 Inferior turbinate Inferior nasal turbinate Concha nasi inferior Inferior turbinate
Maxilloturbinal
Concha inferior
Lower turbinate
1.4.1 Inferior meatus Inferior nasal meatus Meatus nasi inferior Inferior meatus
Lower nasal meatus
1.4.1.1 Nasolacrimal duct opening Hasner’s valve Apertura/ostium ductus Nasolacrimal duct opening
(Naso)lacrimal duct ostium nasolacrimalis
Ostium lacrimale


1.5 Middle turbinate Middle nasal turbinate Concha nasi media Middle turbinate
First (persisting) ethmoturbinal
First ethmoidal turbinate
Middle concha
Concha media
1.5.1 Basal lamella of middle Ground lamella of middle turbinate n.e. Basal lamella of middle
turbinate Third basal lamella turbinate
1.5.2 Paradoxically curved Concave middle turbinate n.e. Paradoxical middle turbinate 3–26%
middle turbinate Inverse middle turbinate
1.5.3 Concha bullosa (of middle Bullosa middle turbinate/concha n.e. Concha bullosa (of middle 17–36%
turbinate) turbinate) ~50% in Turkish
1.5.3.1 Interlamellar cell Interlamellar cell n.e. Interlamellar cell
1.6 Middle meatus Meatus medius Meatus nasi medius Middle meatus
Middle nasal meatus
1.7 Ostiomeatal complex Ostiomeatal complex n.e. Ostiomeatal complex
1.8 Superior turbinate Superior nasal turbinate Concha nasi superior Superior turbinate
Second (persisting) ethmoturbinal
Second ethmoidal turbinate
Superior concha
Concha superior
1.8.1 Concha bullosa (of superior Concha bullosa (of superior turbinate) n.e. Concha bullosa (of superior 1–2%
turbinate) turbinate)
1.9 Superior meatus Superior nasal meatus Meatus nasi superior Superior meatus
Upper nasal meatus
1.10 Supreme turbinate Supreme nasal turbinate Concha nasi suprema Supreme turbinate
Third (persisting) ethmoturbinal
Third ethmoidal turbinate
Supreme concha
Highest nasal concha
Concha (nasalis) suprema
(Morgagni)
1.11 Supreme meatus Supreme nasal meatus n.e. Supreme meatus
2 Spheno-ethmoidal recess Recessus spheno-ethmoidalis Recessus sphenoethmoidalis Spheno-ethmoidal recess
3 Sphenopalatine foramen Foramen of sphenopalatine artery Foramen sphenopalatinum Sphenopalatine foramen
4 Olfactory cleft Olfactory ridge Sulcus olfactorius Olfactory cleft
Olfactory groove


Olfactory fissure
Olfactory area
4.1 Olfactory fibre(s) Olfactory fibre(s) Fila olfactoria Olfactory fibre(s)
Fila olfactoria (sing: filum olfactorium)
5 Choana Posterior nasal aperture(s) Choana (plur: choanae) Choana
(plur: choanae) Nares posteriores Apertura nasalis posterior
6 Maxillary sinus Maxillary antrum Sinus maxillaris Maxillary sinus
6.1 Maxillary sinus ostium Maxillary opening n.e. Maxillary sinus ostium
6.1.1 Accessory maxillary ostium Additional maxillary sinus ostium n.e. Accessory ostium 5% normal
(plur: ostia) 25% CRS patients
6.1.2 Maxillary hiatus Maxillary hiatus Hiatus maxillaris Maxillary hiatus
6.2 Infraorbital nerve canal Infraorbital canal Canalis infraorbitalis Infraorbital canal
Continued


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Table 33.1 Terminology—cont’d
Present ‘surgical’ Rhinological and anatomical synonyms Terminologia Anatomica Suggested English Frequency of variant
terminology (textbooks, literature) terminology (position paper) in literature*
6.3 Zygomatic recess Recessus zygomaticus n.e. Zygomatic recess
6.4 Alveolar recess Recessus alveolaris n.e. Alveolar recess
6.5 Prelacrimal recess Prelacrimal recess n.e. Prelacrimal recess
6.6 Lacrimal eminence Eminentia lacrimalis n.e. Lacrimal eminence
Bulging of nasolacrimal duct
6.7 Canine fossa Canine fossa Fossa canina Canine fossa
Fossa canina
6.8 Anterior (nasal) fontanelle Fontanella nasal anterior n.e. Anterior fontanelle
6.9 Posterior (nasal) fontanelle Fontanella nasal posterior n.e. Posterior fontanelle
6.10 Maxillary artery (Internal) maxillary artery Arteria maxillaris Maxillary artery
7 Ethmoidal complex Ethmoid Cellulae ethmoidales Ethmoidal complex
Ethmoidal sinus(es)
Ethmoidal labyrinth
Labyrinthus ethmoidalis
7.1 Anterior ethmoidal cells Anterior ethmoid Cellulae ethmoidales anteriores Anterior ethmoidal cells
Sinus ethmoidalis anterior
Cells of anterior ethmoid
Anterior ethmoid complex
7.2 Middle ethmoidal cells Cellulae ethmoidales mediae t.b.a.
7.3 Posterior ethmoidal cells Posterior ethmoid Cellulae ethmoidales posteriores Posterior ethmoidal cells
Sinus ethmoidalis posterior
Dorsal ethmoidal cells
Cells of posterior ethmoid
7.4 Anterior ethmoidal artery Anterior ethmoidal artery Arteria ethmoidalis anterior Anterior ethmoidal artery
7.5 Middle ethmoidal artery Third ethmoidal artery n.e. Accessory ethmoidal artery (Var) up to 45% if it
Accessory ethmoidal artery equates to any
Intermediate ethmoidal artery situation where


Arteria ethmoidalis tertia (40%) >2 arteries
7.6 Posterior ethmoidal artery Posterior ethmoidal artery Arteria ethmoidalis posterior Posterior ethmoidal artery
8 Anterior ethmoidal Anterior ethmoidal cells Cellulae ethmoidales anteriores Anterior ethmoidal complex
complex
8.1 Agger nasi Operculum conchae mediae Agger nasi Agger nasi
8.1.1 Agger nasi cell Pneumatized agger nasi n.e. (cellula ethmoidalis anterior) Agger nasi cell >90%
Agger cell
9 Uncinate process Uncinate process Processus uncinatus Uncinate process
9.1 Deflected uncinate process Doubled middle turbinate n.e. Everted uncinate process 5–22%
Anteriorly curved uncinate process
Everted uncinate process
9.2 Aerated uncinate process Bullous uncinate process n.e. Aerated uncinate process 1–2%
Pneumatized uncinate process
9.3 Basal lamella of uncinate Ground lamella of uncinate process n.e. Basal lamella of uncinate
process Uncinate lamella process
First basal lamella
9.4 Hiatus semilunaris Semilunar hiatus Hiatus semilunaris Inferior semilunar hiatus
Hiatus semilunaris inferior
Semilunar gap
9.4 Hiatus semilunaris Hiatus semilunaris superior n.e. Superior semilunar hiatus (Var)
(superior) Hiatus semilunaris posterior
Superior semilunar hiatus
9.5 Ethmoidal bulla Bulla ethmoidalis Bulla ethmoidalis Ethmoidal bulla
9.5.1 Non-pneumatized Torus bullaris n.e. t.b.a. 8%
ethmoidal bulla
9.5.2 Bulla lamella Second ground lamella n.e. Basal lamella of ethmoidal
Basal lamella of ethmoidal bulla bulla
Second basal lamella
9.5.3 Suprabullar recess Sinus lateralis n.e. Suprabullar recess 71%
Suprabullar cell
Recessus bullaris
9.5.4 Retrobullar recess Hiatus semilunaris superior n.e. Retrobullar recess 94%


9.5.5 Supraorbital recess Supraorbital cell n.e. Supraorbital recess (Var) 17%
Supraorbital ethmoid cell
Cellula orbitalis
9.5.6 Infraorbital cell Haller cell n.e. Infraorbital cell 4–15%
Orbito-ethmoidal cell
9.6 Ethmoidal infundibulum Ethmoidal infundibulum Infundibulum ethmoidale Ethmoidal infundibulum
9.6.1 Terminal recess Terminal recess of ethmoidal infundibulum n.e. Terminal recess (Var) 49–85%
Recessus terminalis
9.7 Frontal recess Recessus frontalis n.e. Frontal recess
Frontal outflow tract
9.7.1 Infundibular cells Infundibular cells n.e. Anterior ethmoidal cells (Var)
9.7.2 Lacrimal cells Lacrimal cells n.e. Anterior ethmoidal cells (Var) 33%
9.7.3 Nasofrontal duct Frontal outflow tract Ductus nasofrontalis t.b.a.
Frontal recess
9.7.4 Maxillary crest Lacrimal crest n.e. Lacrimal bulge
Maxillary line
9.7.5 Ethmoidal crest Crista ethmoidalis Crista ethmoidalis Ethmoidal crest
Ethmoidal crest of the palatine bone


Nose, nasal cavity and paranasal sinuses
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Table 33.1 Terminology—cont’d
Present ‘surgical’ Rhinological and anatomical synonyms Terminologia Anatomica Suggested English Frequency of variant
terminology (textbooks, literature) terminology (position paper) in literature*
9.7.6 Frontal sinus drainage Nasofrontal duct n.e. Frontal sinus drainage
pathway Frontal outflow tract pathway
Frontal recess
10 Frontal sinus Frontal sinus Sinus frontalis Frontal sinus
10.1 Interfrontal septum Frontal sinus septum Septum sinuum frontalium Frontal intersinus septum
10.2 Frontal sinus infundibulum Frontal sinus infundibulum n.e. Frontal sinus infundibulum
10.3 Intrafrontal cells Frontal sinus cells Bullae frontales Frontoethmoidal cells (Var)
Kuhn type 3/4 cells (sing: bulla frontalis)
10.4 Intersinus septal cell Intersinus septal cell n.e. Intersinus septal cell
10.5 Frontal bulla Frontal bulla n.e. (cellula ethmoidalis anterior) t.b.a. (Var)
10.6 Frontal sinus ostium Frontal ostium Apertura sinus frontalis Frontal sinus opening
Opening of frontal sinus
10.7 Frontal beak Nasal beak Spina frontalis (ossis frontalis) Frontal beak
Superior nasal spine Spina nasalis interna
11 Posterior ethmoidal Posterior ethmoidal cells Cellulae ethmoidales posteriores Posterior ethmoidal complex
complex
11.1 Onodi cell Spheno-ethmoidal cell n.e. (cellula ethmoidalis posterior) Sphenoethmoidal cell 4–65%
Gruenwald cell 8–14% Caucasians,
26–29% Asians
11.2 Basal lamella of superior Fourth basal lamella n.e. Basal lamella of superior
turbinate turbinate
11.3 Lamina papyracea Medial orbital wall Lamina orbitalis ossis ethmoidalis Lamina papyracea
Papyraceous lamina
11.4 Orbital apex Orbital apex n.e. Orbital apex


11.5 Anulus of Zinn Common tendinous ring Anulus tendineus communis Anulus of Zinn
Common anular tendon
11.6 Ophthalmic artery Ophthalmic artery Arteria ophthalmica Ophthalmic artery
12 Sphenoid sinus Sphenoid sinus Sinus sphenoidalis Sphenoid sinus
12.1 Intersphenoidal septum Intersphenoidal septum Septum sinuum sphenoidalium Sphenoid intersinus septum
Sphenoid sinus septum
12.2 Accessory sphenoidal Incomplete sphenoidal septations n.e. Sphenoid septations (Var)
septum (plur: septa) Partial sphenoidal septations 76%
Sphenoid sinus subseptations
12.3 Sphenoid sinus ostium Sphenoid (sinus) ostium Ostium (apertura) sinus Sphenoid sinus ostium
Sphenoid (sinus) opening sphenoidalis (plur: ostia
Natural sphenoid ostium sinuum sphenoidalium)
12.4 Planum sphenoidale Sphenoid sinus roof Jugum sphenoidale Planum sphenoidale
Jugum sphenoidale
Sphenoidal yoke
12.5 Sellar floor Floor of sella n.e. Sellar floor
Sellar bulge
12.6 Vidian canal Pterygoid canal Canalis pterygoideus Pterygoid (Vidian) canal
Canalis nervi pterygoidei
12.7 Foramen rotundum Canalis rotundus Foramen rotundum Foramen rotundum
Round foramen
12.8 Lateral recess of sphenoid Lateral recess of sphenoid sinus n.e. Lateral recess of sphenoid (Var)
sinus sinus
12.9 Optic tubercle Optical nerve tubercle Tuberculum nervi optici Optic nerve tubercle
Prominentia nervi optici
12.9.1 Optic nerve canal Eminentia nervi optici Canalis opticus Optic nerve canal (Var)
Optic nerve bulging
Optic nerve canal contour
12.9.2 Carotid artery prominence Prominentia canalis carotici n.e. Carotid artery bulge (Var)


12.9.3 Optico-carotid recess Carotid-optical recess n.e. Optico-carotid recess (Var)
Infraoptical recess
12.9.4 Sternberg’s canal Canalis craniopharyngicus lateralis n.e. Lateral craniopharyngeal 4% adults
(Sternberg’s) canal
13 Sphenoidal rostrum Rostrum Rostrum sphenoidale Sphenoid rostrum
14 Vomerovaginal canal Vomerovaginal canal Canalis vomerovaginalis Vomerovaginal canal
15 Palatovaginal canal Palatovaginal canal Canalis palatovaginalis Palatovaginal canal
16 Skull base Cranial base Basis cranii Skull base
Basicranium
16.1 Inner skull base Internal surface of cranial base Basis cranii interna Inner skull base
17 Anterior cranial fossa Anterior cranial fossa Fossa cranii anterior Anterior cranial fossa
17.1 Olfactory fossa Ethmoidal notch n.e. Olfactory fossa
Fovea ethmoidalis
17.2 Cribriform plate Lamina cribrosa Lamina cribrosa (ossis Cribriform plate
Roof of inner nose ethmoidalis)
17.2.1 Cribriform foramina Cribriform openings Foramina cribrosa Cribriform foramina
17.2.2 Lateral lamella of Lateral lamella of cribriform plate n.e. Lateral lamella of cribriform
cribriform plate plate
17.3 Ethmoidal roof Foveae ethmoidales (ossis frontalis) n.e. Ethmoidal roof
17.4 Crista galli Crista galli Crista galli Crista galli
17.4.1 Pneumatized crista galli Pneumatized crista galli n.e. Pneumatized crista galli 13%
17.5 Foramen caecum Foramen caecum Foramen caecum Foramen caecum Open (Var: 1.4%)
Continued


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Table 33.1 Terminology—cont’d
Present ‘surgical’ Rhinological and anatomical synonyms Terminologia Anatomica Suggested English Frequency of variant
terminology (textbooks, literature) terminology (position paper) in literature*
18 Middle cranial fossa Middle cranial fossa Fossa cranii media Middle cranial fossa
18.1 Sella Hypophysial fossa Sella turcica Sella (turcica)
Pituitary fossa
18.2 Sellar tubercle Suprasellar notch Tuberculum sellae Tuberculum sellae
18.3 Dorsum sellae Dorsum sellae Dorsum sellae Dorsum sellae
18.4 Anterior clinoid process Anterior clinoid process Processus clinoideus anterior Anterior clinoid process Pneumatized (Var:
(plur: processus clinoidei 16.5%)
anteriores)
18.5 Posterior clinoid process Posterior clinoid process Processus clinoideus posterior Posterior clinoid process
(plur: processus clinoidei
posteriores)
19 Posterior cranial fossa Posterior cranial fossa Fossa cranii posterior Posterior cranial fossa
19.1 Clivus Clivus Clivus Clivus
Abbreviations: n.e., non existent; sing., singular; plur., plural; t.b.a., to be abandoned.
*The frequency of specific variations in the anatomy varies considerably in the literature, which relates to the definitions used, the methodology utilized, i.e. anatomical dissection or imaging, whether the study included normal
controls and/or patients with chronic rhinosinusitis (CRS), and the ethnicity of the subjects.
(With permission from Lund VJ, Stammberger H, Fokkens WJ, et al 2014 European position paper on the anatomical terminology of the internal nose and paranasal sinuses. Rhinology 50:Supp 24:1–34.)
The proportions of the nose and face, both from in front and from the
side, are of enormous significance to the rhinoplastic surgeon. Aesthetic
proportions of the nose vary depending on sex, age, ethnicity and facial


characteristics; however, ranges of normality are described to assist in
aesthetic assessment (Akguner et al 1998). The female nose is slightly
smaller and narrower than the male nose; it is often slightly concave in
profile view, with a slightly obtuse nasolabial angle (increased tip rota-
tion). In terms of overall proportion, the face may be divided into hori-
zontal thirds and vertical fifths, with the nose occupying the middle
section of each. The width of the nose is roughly 70% of the length; the
width of the alar base is usually equal to the intercanthal distance. The
height of the nose is defined by tip projection, where the proportion of
the length of a line from the tip to the alar groove to the length of a
line from nasion to alar groove is in the range of 0.55–0.60. The nasola-
bial angle, reflecting upward rotation of the nose from the upper lip,
normally lies within a range of 105–120° in females and 90–105° in
males. On basal view, the nose is roughly shaped as an equilateral tri- A
angle. The nares usually measure 1.5–2 cm anteroposteriorly and
0.5–1 cm transversely, and are narrower in front; they occupy approxi-
mately two-thirds of the height of the base. The midline columella,
containing the caudal end of the nasal septum and the medial crura of
the lower lateral cartilages, usually extends 3–5 mm below the nares on
lateral views (Fig. 33.2).
B
Fig. 33.2 The adult male nose. A, Basal view. B, Frontal view. The face
can be divided into horizontal thirds and vertical fifths, with the nose filling
the central segment in terms of both width and height. The basal view
may also be divided into horizontal thirds, with the nostrils filling the lower
two-thirds.


External nose
557
33
RETPAHC
A B C
Nasal bone Major alar cartilage
Frontal process of maxilla
Septal cartilage
Lateral process of
septal cartilage
Superior margin of
septal cartilage
Major alar
cartilage
Naris Septal cartilage Minor cartilages of ala Alveolar process of maxilla
D E
Lacrimal bone
Nasal spine of frontal bone Superior concha
Perpendicular plate of
ethmoid Middle concha
Sphenoidal sinus Nasal bone
Uncinate process of ethmoid
Pituitary fossa Nasal bone
Occipital bone
Septal cartilage Frontal process
of maxilla
Lateral process
of septal
cartilage
Vomer
Maxilla,
palatine process
Palatine bone, Major alar
horizontal plate Incisor crest Medial pterygoid plate of cartilage
sphenoid bone
Minor alar
Perpendicular plate cartilage
of palatine bone
Inferior concha
Fig. 33.3 The bony and cartilaginous skeletons of the nose. A, The external nose, frontal view. B, The external nose, lateral view. C, An inferior view of
the cartilages. D, The nasal cavity, medial wall. E, The nasal cavity, lateral wall (left side).
Soft tissue areas of the nose BONES AND CARTILAGE
Four soft tissue areas of the nose lack cartilaginous support. They have Bony skeleton of the external nose
been given numerous eponymous names and descriptions, but were
reclassified by Huizing (2003). The piriform aperture has sharp edges. It is bounded below and laterally
by the maxilla and above by the nasal bones (Fig. 33.3). The lateral
Paraseptal soft tissue area
part of the inferior edge of the piriform aperture merges into its lateral
The supratip area contains the paired lateral cartilages, which gradually wall, which is formed by the frontal process of the maxilla. It is bounded
separate from the septum to a level just above the septal angle. The above by the nasal part of the frontal bone and superomedially by the
amount of flare varies, and encloses a small paraseptal soft tissue trian- lateral edge of the nasal bone.


gle on each side of the septum. The paired nasal bones vary in thickness and width, which is of
significance in planning osteotomies. They are thickest and widest at
Lateral soft tissue area
the nasofrontal suture, narrow at the nasofrontal angle before they
The lateral margin of the lateral cartilage, the piriform aperture and the widen, and become thinner 9–12 mm below the nasofrontal angle.
cranial margin of the lateral crus of the major alar cartilage enclose a They average 25 mm in length but this can vary widely. The perpendicu-
triangle containing loose fibroareolar tissue, the transverse portion of lar plate of the ethmoid bone (part of the bony nasal septum) articu-
nasalis, and one or more small sesamoid cartilages. lates with the undersurface of the nasal bones and provides support to
the dorsum of the nose. A midline bony spine deep to the fused nasal
Caudal lobular notch
bone projects inwards to articulate with the perpendicular plate of the
The domal segment of the intermediate crus of the major alar cartilage ethmoid and fuses with the fibrous tissue connecting the lateral nasal
has a small indentation. The apex of the nostril is a soft tissue triangle cartilages and cartilaginous septum. This is known as the keystone area
with little soft tissue separating the internal and external skin. Incisions and provides essential support to the nasal dorsum.
in this area may cause unsightly scarring and deformity.
Alar soft tissue area Fractures of the nasal bones The most common injury to the
The lateral crus fails to extend to the lateral limit of the lobule, forming facial skeleton is a fracture of the nasal bones. In simple fractures, the
the fourth soft tissue area. break often occurs between the proximal thicker bone and the thinner


NosE, NAsAL CAviTy ANd PARANAsAL siNusEs
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NoiTCEs
bone distally. Displaced fractures require reduction to avoid cosmetic
deformity. The terminal branch of the anterior ethmoidal nerve and its
accompanying vessels are at risk when injuries involve the dorsum of
the nose.
Cartilaginous skeleton of the external nose
The cartilaginous framework consists of the paired lateral and major
cartilages and several minor alar nasal cartilages (see Fig. 33.3).
Lateral (superior/upper lateral)
nasal cartilage Levator labii superioris
alaeque nasi
The lateral nasal cartilage is triangular, and its anterior margin is thicker Nasalis
than the posterior margin. The upper part fuses with the septal cartilage,
but anteroinferiorly, it may be separated from it by a narrow fissure. Depressor septi Naris
The superior margin of the lateral nasal cartilage is attached to the nasal nasi
bone and frontal process of the maxilla, and the inferior margin is con-
nected by fibrous tissue to the lateral crus of the major alar cartilage.
Laterally, the cartilage is attached indirectly to the margins of the piri-
form aperture by loose fibroareolar connective tissue, which may also
contain one or more small sesamoid cartilages. The angle formed
between the caudal end of the lower lateral and the septum, the internal
nasal valve, is usually between 10 and 15° and represents the narrowest
cross-sectional area and the area of greatest airflow resistance. Structural Fig. 33.4 The nasal musculature. (From Drake RL, Vogl AW, Mitchell A
abnormalities in this area are likely to produce symptomatic nasal (eds), Gray’s Anatomy for Students, 2nd ed, Elsevier, Churchill
obstruction. Livingstone. Copyright 2010.)
Major alar (lower lateral) cartilage
The major alar cartilage is a highly complex, thin, flexible plate, which Actions Procerus draws down the medial angle of the eyebrow and
is integral to the nasal lobule. It lies below the upper lateral cartilage produces transverse wrinkles over the bridge of the nose. It is active in


and curves acutely around the anterior part of its naris. The medial part, frowning and ‘concentration’, and helps to reduce the glare of bright
the narrow medial crus (septal process), is loosely connected by fibrous sunlight. Not surprisingly, it is a common target in non-surgical facial
tissue to its contralateral counterpart and to the anteroinferior part of rejuvenation techniques, using botulinum toxin.
the septal cartilage. The intermediate crus forms the margin of the apex
of the nostril. The domes give rise to the tip-defining points of the nose. Nasalis
The lateral crus lies lateral to the naris and runs superolaterally away Nasalis consists of transverse and alar components. The transverse part
from the margin of the nasal ala. The upper border of the lateral crus (compressor naris) is attached to the maxilla above and lateral to the
of the major alar cartilage is attached by fibrous tissue to the lower incisive fossa, and lateral to the alar part. Its fibres pass upwards and
border of the lateral nasal cartilage. Its lateral border is connected to medially, and expand into a thin aponeurosis that merges with its
the frontal process of the maxilla by a tough fibrous membrane contain- counterpart across the bridge of the nose, with the aponeuroses of
ing three or four minor alar cartilages. The junction between the lateral procerus, and with fibres from levator labii superioris alaeque nasi.
crura of the major alar and lateral cartilages is variable; the two edges Fibres from the transverse part may also blend with the skin of the
may form a ‘scroll’, with an outcurving of the lateral cartilage meeting nasolabial and alar folds. The alar part (pars alaris or dilator naris
an incurving of the major alar cartilage, in which case the lateral crus posterior) is attached to the maxilla above the lateral incisor and canine,
is then the more lateral at the junction. The lateral crus is shorter than lateral to the bony attachment of depressor septi, and medial to the
the lateral margin of the naris; the most lateral part of the margin of transverse part, with which it partly merges. Its fibres pass upwards


the ala nasi is fibroadipose tissue covered by skin. In front, the angul- and anteriorly, and are attached to the skin of the ala above the lateral
ations or ‘domes’ between the medial and lateral crurae of the major crus of the lower lateral cartilage, and to the posterior part of the
alar cartilages are separated by a notch palpable at the tip of the nose. mobile septum. The pars alaris helps to produce the upper ridge of the
philtrum.
Alar cartilage morphology
Dilator naris anterior (also known as apicis nasi or the small dilator
muscle of the nose) is a very small muscle attached to the upper lateral
Available with the Gray’s Anatomy e-book cartilage, the alar part of nasalis, the caudal margin of the lateral crus
and the lateral alar crus. It encircles the naris and acts as a primary
dilator of the nostril.
MUSCLES
Vascular supply Nasalis is supplied by branches from the facial
The nasal muscle group includes procerus, nasalis, dilator naris anterior, artery and from the infraorbital branch of the maxillary artery.
depressor septi and levator labii superioris alaeque nasi (Fig. 33.4, see
Figs 30.17, 30.18). These muscles are involved in respiration and facial Innervation Nasalis is supplied by the buccal branch of the facial
expression. Any or all of these muscles may be absent in cleft lip de- nerve. It may also be supplied by the zygomatic branch of the facial
formities with corresponding functional and aesthetic consequences. nerve.
Procerus Actions The transverse part compresses the nasal aperture at the junc-
Procerus is a small pyramidal muscle that lies close to, and is often tion of the vestibule and the nasal cavity. The alar parts draw the alae
partially blended with, the medial side of the frontal part of occipito- and posterior part of the columella downwards and laterally, and so
frontalis. It arises from a fascial aponeurosis attached to the periosteum assist in widening the nares and in elongating the nose. They are active
covering the lower part of the nasal bone, the perichondrium covering immediately before inspiration. Dilator naris anterior and the alar part


the upper part of the lateral nasal cartilage, and the aponeurosis of the of nasalis (dilator naris posterior) probably function to prevent collapse
transverse part of nasalis. It is inserted into the glabellar skin over the of the nasal valve during inspiration. Their electromyographic activity
lower part of the forehead between the eyebrows. is directly proportional to ventilatory resistance and is modified by
signals that travel from pulmonary mechano- and pressure receptors via
Vascular supply Procerus is supplied mainly by branches from the afferent vagal pathways to the brainstem respiratory centre; the efferent
facial artery. limb of the reflex arc runs in the facial nerve.
Innervation Procerus is supplied by temporal and lower zygomatic Depressor septi
branches from the facial nerve (a supply from the buccal branch has Depressor septi lies immediately deep to the mucous membrane of the
been described). upper lip. It is usually attached to the periosteum covering the maxilla


Nose, nasal cavity and paranasal sinuses
558.e1
33
RETPAHC
The medial crus has two components, a footplate segment and a colu- The lateral crus may take a highly variable position, being either
mellar segment, which angulate with each other in two planes; they convex or concave, or a combination of both, in medial and lateral
diverge in the basal plane, and rotate upwards in the lateral plane. There portions; asymmetry from side to side has been reported in over half
is usually asymmetry in the pairs of medial crura. of anatomical specimens.
The medial crus joins the intermediate crus at what is usually A chain of lateral accessory cartilages with dense fibrous attachments
the most convex point of the columella, known as the columellar connect to the lateral crus and the piriform aperture, and to the anterior
breakpoint. nasal spine through connection in the floor of the nose.
The intermediate crus is also described in two components. The
Tip support
lobular segment is usually flared and forms the transition between the
medial crus and the domal segment of the intermediate crus. The domal The inherent strength and shape of the cartilaginous framework, and
segment may be convex, producing an aesthetically pleasing tip; flat, its attachments to surrounding structures, provide support to the tip of
giving a ‘boxy’ appearance; or convex, producing a ‘double-dome’. The the nose. Typically, ‘major’ and ‘minor’ tip support mechanisms are
domal or tip-defining points are usually formed by the most anterior described.
projection of the domal segment. The amount of divergence of the
domes, and the thickness of the overlying soft tissue envelope, deter- Major tip support mechanisms The major mechanisms support-
mine the relative position of the tip-defining points. The dome projects ing the tip are: the size, shape and strength of the major alar cartilages;
up to 8–10 mm caudal, and 3–6 mm anterior, to the anterior septal the medial crural footplate attachment to the caudal part of the septum;
angle, the difference between the two creating the supratip break-point. the attachment of the caudal border of the lateral cartilages to the


Disruption of this relationship with rhinoplasty, with loss of projection cephalic border of the major alar cartilages; and the cartilaginous dorsal
of the tip, may produce a ‘polybeak’ deformity. septum.
Classically, transverse connective tissue fibres have been described
binding the medial and intermediate crura; interdomal, intercrural and Minor tip support mechanisms The minor mechanisms support-
septocrural ligaments have been described. Cadaveric studies by Zhai ing the tip are: the ligamentous sling spanning the domes of the lower
et al (1995) disputed the presence of transverse fibres, and found that lateral cartilages (i.e. the interdomal ligament); the sesamoid complex
all connective tissue fibres run parallel to the cartilages. These findings of major alar cartilages; the attachment of the major alar cartilages to
notwithstanding, the fibrous connections along the length of the medial the overlying skin/soft tissue envelope; the nasal spine; and the mem-
and intermediate crura form a single functional unit in the tip. branous septum.
The large lateral crus determines the shape of the alar lateral wall. Rhinoplasty approaches, either through an intercartilaginous inci-
Medially, it is a continuation of the intermediate crus, while laterally it sion between the lateral and the major alar cartilages (closed rhino-
connects with accessory cartilages. It runs at the caudal edge of the alar plasty), or through an incision caudal to the major alar cartilages and
rim in the anterior half, then moves cephalically, leaving a soft tissue degloving the entire cartilaginous framework (open rhinoplasty),
area in the rim laterally. Typically, the longitudinal axis of the lateral disrupt the tip support mechanisms; the integrity of these mechanisms
crus forms an angle of 45° with the septum. More vertical, or cephalic, must be restored during the procedure to prevent loss of tip support
positioning results in a ‘parenthesis’ tip deformity. and subsequent tip ptosis.


Nasal cavity
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33
RETPAHC
above the central and lateral incisors and the anterior nasal spine, and Ala of vomer
to the fibres of orbicularis oris above the central incisor. Its fibres pass Vaginal process of
to the columella, the mobile part of the nasal septum and the base of medial pterygoid plate
the medial crus of the nasal cartilage. A few muscle slips may pass
between the medial crura into the nasal tip. Depressor septi may be
absent or rudimentary.
Sphenoidal process
of palatine bone
Vascular supply Depressor septi is supplied by the superior labial
branch of the facial artery.
Innervation Depressor septi is innervated by the buccal branch, and Medial pterygoid
plate of sphenoid
sometimes by the zygomatic branch, of the facial nerve.
Actions Depressor septi pulls the columella, the tip of the nose and
Pyramidal process
the nasal septum downwards. It tenses the nasal septum at the start of
of palatine bone
nasal inspiration and, with the alar part of nasalis, widens the nasal
aperture, as well as causing the nose to ‘dip’ when some people smile. Choanae Horizontal plate
Pterygoid hamulus of palatine bone
Levator labii superioris alaeque nasi
Fig. 33.5 A posterior view of the choanae.
Levator labii superioris alaeque nasi arises from the upper part of the
frontal process of the maxilla and, passing obliquely downwards and
laterally, divides into medial and lateral slips. The medial slip blends
into the perichondrium of the lateral crus of the major alar cartilage of CUTANEOUS INNERVATION
the nose and the skin over it. The lateral slip is prolonged into the lateral
part of the upper lip, where it blends with levator labii superioris and Nasal skin is innervated by the infratrochlear and external nasal
orbicularis oris. Superficial fibres of the lateral slip curve laterally across branches of the nasociliary nerve (ophthalmic division, trigeminal


the front of levator labii superioris and attach along the floor of the nerve), and the nasal branch of the infraorbital nerve (maxillary div-
dermis at the upper part of the nasolabial furrow and ridge. ision, trigeminal nerve).
Vascular supply Levator labii superioris alaeque nasi is supplied by
NASAL CAVITY
the facial artery and the infraorbital branch of the maxillary artery.
Innervation Levator labii superioris alaeque nasi is innervated by The nasal cavity is an irregular space between the roof of the mouth
zygomatic and superior buccal branches of the facial nerve. and the cranial base. It is wider below than above, and widest and verti-
cally deepest in its central region, where it is divided by a vertical,
Actions The lateral slip raises and everts the upper lip and raises, midline, osseocartilaginous septum. The bony part of the septum
deepens and increases the curvature of the top of the nasolabial furrow. reaches the posterior limit of the cavity.
The medial slip pulls the lateral crus superiorly, displaces the circumalar The nasal cavity communicates with the paranasal sinuses and opens
furrow laterally, and modifies its curvature; it is a dilator of the naris. into the nasopharynx through a pair of oval openings, the posterior
Depressor septi and the medial slip of levator labii superioris alaeque nasal apertures or choanae. The latter are separated by the post erior
nasi are sometimes described as secondary nasal dilators; there is little border of the vomer, and each is limited above by the vaginal process
evidence that either of these muscles has any direct influence on the of the medial pterygoid plates, laterally by the perpendicular plate of
nasal valve. the palatine bone and the medial pterygoid plate, and below by the
Anomalous nasal muscles horizontal plate of the palatine bone (Fig. 33.5). The param eters of the
intranasal spaces depend on age and gender: growth is usually com-
Anomalous, inconstant, nasal muscles have been described. They
pleted by the age of 16 (Samoliński et al 2007). The adult choana typi-


include anomalous nasi, attached to the frontal process of the maxilla,
cally measures 2.5 cm in vertical height and 1.3 cm transversely; size is
procerus, transverse part of nasalis and the upper lateral cartilage (i.e.
not usually affected by deviations of the nasal septum. The vomerov-
in a region normally devoid of muscle), and compressor narium minor,
aginal and palatovaginal canals are found in the roof of this region.
which passes between the anterior part of the lower lateral cartilage and
Each half of the nasal cavity has a vestibule, roof, floor, medial
the skin near the margins of the nares. The existence of a small levator
(septal) and lateral walls.
septi nasi has been questioned.
Superficial muscular aponeurotic
NASAL VESTIBULE
system (SMAS)
The nasal vestibule lies just inside the naris. It is limited above and
Available with the Gray’s Anatomy e-book
behind by a curved ridge, the limen nasi, raised where the greater ala
of the lateral cartilaginous crus overlaps the lower edge of the lateral
nasal cartilage on each side. On the septal side of the nasal cavity, the
CUTANEOUS VASCULAR SUPPLY AND
superior edge of the medial crus of the major alar cartilage (the medial
LYMPHATIC DRAINAGE intumescence) marks the boundary between the nasal vestibule and the
nasal cavity. The medial wall of the vestibule is formed by a mobile
Nasal skin receives its blood supply from branches of the facial, oph- septum consisting of the columella (which does not contain cartilage)
thalmic and infraorbital arteries. The alae and lower part of the nasal and the underlying medial crura of the alar cartilages.
septum are supplied by lateral nasal and septal branches of the facial
artery, and the lateral aspects and dorsum of the nose are supplied by
the dorsal nasal branch of the ophthalmic artery and the infraorbital ROOF
branch of the maxillary artery. The venous networks draining the exter-
nal nose do not run parallel to the arteries but correspond to arterio- The roof is horizontal in its central part and slopes downwards in front