Nose Anatomy

Last Updated: May 17, 2002

Embryology

The developmental precursors of the nose are the neural crest cells, which
commence their caudad migration towards the midface around the fourth week of
gestation (Photo 1). Two nasal placodes develop inferiorly in a symmetrical
fashion. Nasal pits divide the placodes into medial and lateral nasal processes.
The medial processes become the septum, philtrum, and premaxilla of the nose;
whereas the lateral processes form the sides of the nose. Inferior to the nasal
complex, the stomodeum, or future mouth, forms.

A nasobuccal membrane separates the oral cavity inferiorly from the nasal cavity
superiorly. As the olfactory pits deepen, the choanae are formed. Primitive
choanae form initially, but with continued posterior development, the secondary
or permanent choanae develop. By 10 weeks, differentiation into muscle,
cartilage, and bony elements occurs. Failure of these carefully orchestrated
events in early facial embryogenesis may result in multiple potential anomalies,
including choanal atresia, medial or lateral nasal clefts, nasal aplasia, and
polyrrhinia. Neonates are obligate nasal breathers for the first 6 weeks. When
bilateral choanal atresia is present in a neonate, emergent action is needed

Anatomy

Skin and soft tissues

Like the underlying bony-cartilaginous framework of the nose, the overlying skin
may also be divided into vertical thirds. The skin of the upper third is fairly thick
but tapers into a thinner mid-dorsal region. The inferior third regains the
thickness of the upper third owing to the more sebaceous nature of the skin in
the nasal tip.

The nasal muscles are encountered deep to the skin and are comprised of four
principal groups: the elevators, the depressors, the compressor, and the dilators.
The elevators include the procerus and levator labii superioris alaeque nasi. The
depressors are made up of the alar nasalis and depressor septi nasi. The
compressor of the nose is the transverse nasalis, whereas the dilators are the
dilator naris anterior and posterior. The muscles are interconnected by an
aponeurosis termed the nasal superficial musculoaponeurotic system (SMAS).

The internal nasal lining consists of squamous epithelium in the vestibule. This
transitions to pseudostratified ciliated columnar respiratory epithelium with
abundant seromucinous glands within the nose.
Blood supply

The nose, like the rest of the face, has an abundant blood supply. The arterial
supply to the nose may be principally divided into branches from the internal
carotid, namely the branches of the anterior and posterior ethmoid arteries off of
the ophthalmic artery, and branches from the external carotid, namely the
sphenopalatine, greater palatine, superior labial, and angular arteries.

The external nose is supplied by the facial artery which becomes the angular
artery coursing over the superomedial aspect of the nose. The sellar and dorsal
regions of the nose are supplied by branches of the internal maxillary artery
(namely the infraorbital) and ophthalmic arteries (which are from the internal
carotid system).

Internally, the lateral nasal wall is supplied by the sphenopalatine artery

posteroinferiorly and by the anterior and posterior ethmoid arteries superiorly.
The nasal septum also derives its blood supply from the sphenopalatine and the
anterior and posterior ethmoid arteries with the added contribution of the superior
labial artery (anteriorly) and the greater palatine artery (posteriorly).
Kiesselbach's plexus, or Little's area, represents a region in the anteroinferior
third of the nasal septum where all three of the chief blood supplies to the internal
nose converge.

Veins in the nose essentially follow the arterial pattern. They are significant for
their direct communication with the cavernous sinus and for their lack of valves --
which make them dangerous for potential intracranial spread of infection.

Lymphatics

Lymphatics arise from the superficial mucosa and drain posteriorly to the
retropharyngeal nodes and anteriorly to the upper deep cervical nodes and/or
submandibular glands

Nerves

The sensation of the nose is derived from the first 2 branches of the trigeminal
nerve. The following outline effectively delineates the respective sensory
distribution of the nose and face of the trigeminal nerve.

I. The Ophthalmic division

1. Lacrimal- skin of lateral orbital area except lacrimal gland

2. Frontal- skin of forehead and scalp

a. supraorbital- eyelid skin, forehead, and scalp

 b. supratrochlear- medial eyelid and medial forehead

3. Nasociliary- skin of nose, mucous membrane of anterior nasal cavity

a. anterior ethmoid- anterior half of nasal cavity

i. internal- ethmoid and frontal sinuses

ii. external- nasal skin from rhinion to tip

b. posterior ethmoid- superior 1/2 of nasal cavity, namely the

sphenoid and ethmoids.

c. intratrochlear- medial eyelids/palpebral conjunctiva, nasion and

bony dorsum

II. Maxillary Division

1. Maxillary

2. Infraorbital- external nares

3. Zygomatic

4. Superior posterior dental

5. Superior anterior dental- mediates sneeze reflex

6. Sphenopalatine- divides into lateral and septal branches and conveys

sensation from posterior andcentral regions of the nasal cavity

The parasympathetic supply is derived from the greater superficial petrosal

(GSP) branch of cranial nerve VII. The GSP joins the deep petrosal nerve
(sympathetic supply) which comes from the carotid plexus to form the vidian
nerve in the vidian canal. The vidian nerve travels through the pterygopalatine
ganglion (with only the parasympathetics synapsing here) to the lacrimal gland
and glands of the nose and palate via the maxillary division of the trigeminal
nerve.

Bony anatomy

Superiorly, the paired nasal bones are attached to the frontal bone (Photo 3).
Superolaterally, they are connected to the lacrimal bones, and inferolaterally they
are attached to the ascending processes of the maxilla. Posterosuperiorly, the
bony nasal septum is composed of the perpendicular plate of the ethmoid (Photo
5). Posteroinferiorly lies the vomer, which in part forms the choanal opening into
the nasopharynx. The floor is comprised of the premaxilla and palatine bones.
The lateral nasal walls contain 3 pairs each of small, thin, shell-like bones: the
superior, middle, and inferior conchae, which form the bony framework of the
turbinates. Lateral to these curved structures lies the medial wall of the maxillary
sinus.

Inferior to the turbinates lies a space called a meatus, with names corresponding
to the above turbinate, eg, superior turbinate, superior meatus. The roof of the
nose internally is formed by the cribriform plate of the ethmoid. Posteroinferior to
this structure, sloping down at an angle, is the bony face of the sphenoid sinus.

Cartilaginous pyramid

The cartilaginous septum extends from the nasal bones in the midline above to
the bony septum in the midline posteriorly, then down along the bony floor. It
assumes a quadrangular shape. Its upper half is flanked by 2 triangular-to-
trapezoidal cartilages, the upper lateral cartilages. These upper lateral cartilages
are fused to the dorsal septum in the midline and attached to the bony margin of
the pyriform aperture laterally by loose ligaments. The inferior ends of the upper
lateral cartilages are free. The internal area or angle formed by the septum and
upper lateral cartilage constitutes the internal valve. Adjacent sesamoid
cartilages may be found lateral to the upper lateral cartilages in the fibroareolar
connective tissue. These are found variably.

Beneath the upper lateral cartilages lie the lower lateral cartilages(Photo 4). The
paired lower lateral cartilages swing out from medial attachments to the caudal
septum in the midline called the medial crura, to an intermediate crus area, and
finally flare out superolaterally as the lateral crura. These cartilages are
frequently mobile, in contradistinction to the upper lateral cartilages.

In some individuals, evidence of a "scroll" may exist, that is, an outcurving of the
lower borders of the upper lateral cartilages and an incurving of the cephalic
borders of the alar cartilages. Several variations exist (Photo 6).

Structure

External Nasal Anatomy (Photo 2)

1. Subunits - Dorsum, sidewalls, hemilobules, alae, soft triangles and the

columella (Photo 7)

2. Ethnic influence

Caucasian - Leptorrhine
African American - Platyrrhine
 Hispanic - Paraleptorrhine
Asian - Subplatyrrine

3. External valve - Variable area dependent on size, shape and the strength of
the lower lateral cartilage.

Internal Nasal Anatomy

1. Septum - midline bony and cartilaginous structure divides the nose into two
similar halves.

2. Lateral nasal wall/paranasal sinuses - Superior, middle, and inferior concha

form corresponding superior, middle, and inferior meatus on the lateral nasal
wall.

Superior meatus - drainage area for posterior ethmoid cells and sphenoid
sinus

Middle Meatus - drainage of anterior ethmoid, maxillary and frontal

sinuses

Inferior Meatus - drainage of nasolacrimal duct

3. Internal Nasal Valve - Area bounded by upper lateral cartilage, septum, nasal
floor and anterior head of the inferior turbinate. This comprises the narrowest
portion of the nasal airway in the leptorrhine nose.

Nasal analysis

The nose can be broken down conveniently into several subunits: the dorsum,
the sidewalls (paired), the hemilobules (paired), the soft triangles (paired), alae
(paired), and the columella. Viewing the external nasal anatomy by subunits is
important because defects that span an entire subunit are usually repaired by
reconstruction of that subunit. Dr Gary Burget suggests replacement of the entire
subunit if more than 50% of the subunit is lost during resection. Aesthetically, the
nose from the nasion (nasofrontal junction) to the columella-labial junction ideally
occupies one third of the face in the vertical dimension. From ala to ala, it should
ideally occupy one fifth of the horizontal dimension of the face.

The nasofrontal angle between the frontal bone and nasion is usually 120
degrees, slightly more acute in males. The nasofacial angle, the slope of the
nose compared to the plane of the face, is approximately 30-40 degrees. The
nasolabial angle between the columella and philtrum is about 90-95 degrees in
males and 100-105 degrees in females. On profile, normal columella show, ie,
the height of the nasal aperture visible, runs between 2-4 mm. The dorsum
should be straight. From below, the alar base forms an isosceles triangle, with
the apex at the infratip lobule, just beneath the tip. Appropriate nasal tip
projection, the distance of the tip from the face, is judged using the Goode rule.
Tip projection should be 55-60% of the distance between the nasion and tip-
defining point. A columellar double break may exist, marking the transition
between the intermediate crus of the lower lateral cartilage and the medial crus.

Pictures

Caption: Picture 1. Nasal embryology

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Caption: Picture 2. Nasal anatomy

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Caption: Picture 3. Nasal anatomy, reprinted with authors permission

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Caption: Picture 4. Base anatomy, reprinted with authors permission

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Caption: Picture 5. Nasal septum is formed by the quadrangular cartilage, the
vomer, the perpendicular plate of the ethmoid and aspects from the premaxilla and
palatine bones

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Caption: Picture 6. Nasal scroll

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Caption: Picture 7. Nasal subunits include the dorsum, sidewalls, lobule, soft
triangles, ala and the columella

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