|Year : 2020 | Volume
| Issue : 2 | Page : 244-250
The effect of deviated nasal septum on aesthetic appearance of the nose
Mohamed Abdelzaher M Rashad Abdel-Hady1, Hoda A Ibrahim1, Ramadan Hat-hout2
1 Department of Otorhinolaryngology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
2 Department of Otorhinolaryngology, Ministry of Health, Cairo, Egypt
|Date of Submission||20-Mar-2020|
|Date of Decision||08-Apr-2020|
|Date of Acceptance||14-Apr-2020|
|Date of Web Publication||29-Jun-2020|
MD Mohamed Abdelzaher M Rashad Abdel-Hady
Prof. of Otorhinolaryngology Faculty of Medicine for Girls Al-azhar University, Cairo
Source of Support: None, Conflict of Interest: None
Background The deviated nasal septum affects the aesthetic appearance of the nose, as a well-known phrase projects ‘As the septum goes, so goes the nose.’ The nasal septum is the central structure supporting the framework of the nose.
Aim To evaluate the relationship between nasal septum deformities and its effects on aesthetic appearance of the nose, and the management of each effect.
Patients and methods A total of 30 patients who underwent septorhinoplasty between April 2016 and December 2019 were evaluated prospectively. This was done in Al-Zahraa University Hospital. Patients who had nasal deformities owing to septal deformities were included.
Results Regarding interference with nasal septum in rhinoplasty operation, only two (6.7%) cases were done without septoplasty, whereas 28 (93.3%) cases were done with septoplasty. In 93.33% of the cases, nasal septum affected the shape of the nose, and in only 6.67% of the cases, the nasal septum did not affect the shape of the nose.
Conclusion The deviated nasal septum affects the aesthetic appearance of the nose, but not all parts of septum affect it. Bony part does not affect the shape of the nose and not all types of deviations of the septum. However, deviations that reach the dorsum of the nose or columella surely affect the shape of the nose.
Keywords: deviated nasal septum, nasal deformities, rhinoplasty
|How to cite this article:|
Rashad Abdel-Hady MM, Ibrahim HA, Hat-hout R. The effect of deviated nasal septum on aesthetic appearance of the nose. Sci J Al-Azhar Med Fac Girls 2020;4:244-50
|How to cite this URL:|
Rashad Abdel-Hady MM, Ibrahim HA, Hat-hout R. The effect of deviated nasal septum on aesthetic appearance of the nose. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Jul 11];4:244-50. Available from: http://www.sjamf.eg.net/text.asp?2020/4/2/244/288281
| Introduction|| |
The nasal septum is an osseous-cartilaginous structure in the center of the nose that separates the nasal cavity into two symmetrical nostrils .
Deviated nasal septum (DNS) is a common anatomic variation in healthy adults, affecting 80% of the people, most of them unknowingly .
Septum deformities may cause breathing and sleeping problems, as well as chronic upper and lower respiratory tract infections, which can affect the whole life of a patient; they can also cause curvatures in the nasal axis resulting in aesthetic imperfections .
DNS occurs when the septum is shifted away from the midline. It is most frequently caused by impact nasal trauma, such as a blow to the face. It can also be a congenital disorder caused by compression of the nose during childbirth .
Different classifications have been described for the external nasal deformities. Jang et al.  use five categories to describe if the bony and cartilaginous dorsum are tilted or bent and in which direction .
Usually, the diagnosis of DNS is based on patient’s symptoms and clinician physical nasal examinations, which are subjective . Computed tomography of the nose and acoustic rhinometry are the other diagnostic tools that are often used to evaluate DNS objectively .
| Aim|| |
The aim was to evaluate the relationship between nasal septum deformities and its effects on aesthetic appearance of the nose, and the management of each effect.
| Patients and methods|| |
This was a prospective study conducted on 30 patients from Al-Zahraa University Hospital between April 2016 and December 2019. The patients provided written informed consent for the publication and the use of their images. FMG-IRB Decision was approved Number 202002158 at 19 February, 2020.
Inclusion criteria were adults between 16 and 60 years of age, of both sexes, who were complaining of nasal disfiguration owing to septum deformities.
Exclusion criteria were patients who refused to join the study, as well as patients who have uncontrolled chronic medical diseases and psychic problems.
- Clinical evaluation included full history taking, general examination, and ENT examination.
- Local examination of the nose was fully conducted for each patient, starting with inspection, palpation, and internal nasal examination, in addition to special tests.
- Special tests included Cottle test, modified Cottle test, tip recoil test, superior tip rotation test, and Alar ballottement test.
- Rhinoplasty photography analysis: the four standard rhinoplasty views are frontal, right/left lateral, and basal view, and sometimes additional views used as oblique, helicopter, and extended basal views are taken.
- Radiological evaluation. Computed tomographic scan Para Nasal Sinuses (PNS) axial and coronal views were done for all patients.
- Laboratory evaluation. Routine preoperative investigations are carried out.
Preoperative preparation of the patient
All patients were interviewed by the surgeon regarding their complaints, their expectations, and their possible questions about the surgery. Possible complications and postoperative instructions were explained. A written consent was signed out.
Open rhinoplasty approach was done in 24 patients, whereas six patients underwent closed rhinoplasty approach. General anesthesia was used, with disinfection with betadine solution. Injection of nasal dorsum, nasal septum, columella, and lower lateral cartilages (LLCs) was done with 1/2 00 000 adrenaline.
Septoplasty may be done first to correct the septal deviation, spur, release of internal forces of nose, and obtaining a septal cartilage graft before any other steps needed according to every case.
Dorsal hump reduction: in bony-cartilaginous hump, rasping of the bony part of the hump and excision of a part of dorsal edge of quadrilateral cartilage with upper lateral cartilage without tearing of mucopericondreal lining were done. In cartilaginous hump, resection of the dorsal side of the quadrangular cartilage is enough.
Spreader graft for correction of crooked nose: spreader grafts are introduced between the septum and the upper lateral cartilages.
Osteotomy: it is done if there are deviations in the bony nasal pyramid in crooked nose, and also done after resection of the bony nasal hump to avoid open roof dorsum deformity.
Dorsal onlay graft for correction of saddle nose: it can be taken from septal cartilage, costal cartilage, and iliac crest bone. The graft varies in length, width, and thickness according to the area of the dorsum to be augmented with.
Trimming of the caudal edge of the septum: it is done to correct hanging columella and long nose.
Septal extension graft is used to correct retracted columella or short nose.
Resection of anterior septal angle is done to correct pollybeak nose.
Tip refining includes grafting techniques such as columellar strut and shield graft, and suturing techniques such as interdomal sutures, transdomal sutures, lateral spanning sutures and tip rotation sutures.
Suturing of the septal flaps is done instead of nasal packing.
Postoperative management instructions
Avoiding any manipulation of the nose for the first 3 postoperative weeks. Keeping the external nasal splint dry. Any activities that may cause direct trauma to the nose are prohibited for at least 4–6 weeks after surgery.
Medical treatment included the following:
Broad-spectrum antibiotics, NSAID, and nasal saline irrigation. Bepanthen cream to the stitches site. Sutures and nasal splints are removed at the initial visit on postoperative day 7.
The average follow-up period in this study was 1 year. Follow-up visits implied full postoperative history, both internal and external nasal examination, and postoperative photography.
| Results|| |
The majority of the patients were in the age between 20 and 30 years. There was no specific sex selected, as there were 20 male and 10 female patients ([Table 1] and [Table 2]).
|Table 2 History of trauma and septum examination confirmed by computed tomographic scan PNS|
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Regarding history of trauma, only nine cases were without any past history of trauma. On the contrary, 21 cases had a traumatic event.
Regarding septum examination, 19 cases were bony-cartilaginous deviation, five cases were separate cartilaginous deviation, one case was separate bony deviation, and five cases were normal. Alar-columellar show seven cases were hanging columella and four cases were retracted columella.
Regarding the number of deformities in the cases, only two cases had one deformity, nine cases had two deformities, 10 cases had three deformities, six cases had four deformities, one case had five deformities, and two cases had six deformities ([Table 3]).
|Table 3 Distribution of the first, second, and third most prominent deformity in multideformities cases|
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After rhinoplasty photographic analysis, the first most prominent deformity in between the 13 deformities affected by nasal septum was crooked nose, and the second most prominent deformity was nasal hump.
Regarding interference with nasal septum in rhinoplasty operation, two (6.7%) cases only was done without septoplasty, whereas 28 (93.3%) cases were done with septoplasty.
Regarding the approach of rhinoplasty operation, 24 (80%) cases were done under open approach, and six (20%) cases were done under closed approach ([Table 4]).
|Table 4 Distribution of the graft and types of septal excision used in this study|
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Among 30 cases, only two (6.67%) cases had nasal septum that did not affect the shape of the nose, whereas 28 (93.33%) cases nasal septum that affected the shape of the nose ([Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8]).
|Figure 2 Dorsal onlay graft from iliac crest bone intraoperative before and after applying it.|
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|Figure 4 A 21-year-old male patient had crooked nose owing to deviation of the nasal septum. Preoperative and postoperative photographic views of frontal, oblique, and basal postoperatively after 1 week. He was managed by septoplasty by hemitransfixion incision, rasping of dorsum of the nose, and osteotomies.|
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|Figure 5 A 26-year-old male patient had nasal hump who was managed by hump reduction by rasping of the bony part and cephalic resection of quadrilateral cartilage. Preoperative and postoperative lateral views, as well as postoperative results after 1 month.|
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|Figure 6 An 18-year-old male patient had saddle nose owing to nasal trauma who was managed by dorsal onlay graft by iliac crest graft. Preoperative and postoperative lateral view, as well as postoperative results after 2 weeks..|
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|Figure 7 A 28-year-old male patient had pollybeak nose owing to overprojection of anterior septal and was managed by cephalic resection of quadrilateral cartilage angle. Preoperative and postoperative photographic lateral views, as well as postoperatively after 1 week.|
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|Figure 8 Pie chart showing the result of septum affection on the shape of the nose.|
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| Discussion|| |
Saharia and Sinha  explained in their study how the septum affects the shape of the nose by considering the septum in all its dimensions. When the nasal septum is deficient in dorsoventral dimension, because of septal abscess or after surgery, it causes the saddle nose. On the contrary, when the dorsoventral dimension is larger than normal, a nasal hump is formed. If the anteroposterior dimension is less, it results in retracted columella, and if the anteroposterior length is more, then there is an excessive show of columella (hanging columella). When the nasal septum is shifted from the midline, the nose is said to be a crooked nose. When the septal cartilage does not lie in the maxillary groove, it causes caudal edge dislocation.
In this study, it was found that not all septum parts affect the shape of the nose. The bony part has an indirect effect. The upper one third of the nose is mainly affected by nasal bones, and the lower two thirds are mainly affected by the cartilaginous part of the septum, but there are other parts that affect this area of the nose, such as LLC, nasal spine, and maxillary crest.
Parrilla et al.  had described in their study that it does not have aesthetic involvement of the nose.
Regarding septum examination, 25 (83%) cases had nasal septal deviations, and five (16.67%) cases only were semistraight. In our study, we considered the septum in all its deformities, that is, not only its deviations but also deformities of dimensions and angles even when the septum was straight. So, there is no conflict with the study by Sam et al.  who found that 67% of the septal deviated patients had external nasal deformities, whereas 33% were found to have purely septal deviation without external nasal deformities.
Regarding the direct effect of the nasal septum on the shape of the nose in this study, it was found that 28 (93.33%) cases nasal septum that affects the shape of the nose, whereas two (6.67%) cases had nasal septum that did not affect the shape of the nose: the first case had nasal hump on the upper 1/3 of the nasal vault, which was found to be a result of high nasal bones and pulpous nasal tip as a result from broad LLCs, and the second case had a nasal hump, also owing to high nasal bones.
Regarding the numbers of deformities in each case in this study, it was found that 28 cases had more than one deformity; therefore, in the 30 cases of this study, we had 95 deformities. In between the 95 deformities, crooked nose was the first most prominent deformity found in 26 cases, and then nasal hump in 21 cases, then down-rotated nose in nine cases, and then long nose in five cases.
In this study, it was found that there were other many deformities caused by nasal septum, about seven deformities, rather than the six deformities discussed in the literature studies ,.
- Long nose: in this study, five cases had long nose deformity, and most of these cases had more than one deformity.
- When patient is complaining of the nasal length, we should keep in mind the factors that affect it, such as the horizontal thirds of the face, the overall stature of the patient, nasolabial angle, and nasofrontal angle. It was done simply by trimming of caudal edge of the septum, and this technique of management is close to the same technique discussed by Saharia and Sinha .
- Short nose: it is corrected by septal extension graft technique as discussed in many literature studies. Kim and Han  described the correction of the short septum by augmenting the caudal edge of the septum.
- Tension nose: it results from prominent cartilaginous dorsum that creates a tent-pole appearance to the supratip region of the lower dorsum. This is corrected by lowering of the dorsal septal cartilage .
- In this study, the problem in tension nose is excessive height of the septum in the dorsobasal direction and sometimes in the caudal-cranial direction, and it was corrected as discussed by Nease and Deal  by lowering of the dorsal septal cartilage.
- In our study, the tension nose deformity was accompanied with hump nose and long nose deformities, and characterized by narrow nasal dorsum.
- Asian (recessed) nose: Kim and Han  described the Asian nose, but in our study, we did not have a typical Asian nose that had the genetic hypoplastic septum. In Middle Eastern people, may have defect in the dorsum leading to recessed nose.
- Kim and Han  described the correction of the hypoplastic septum achieved by augmenting in anterior and caudal direction was considered the main focus in the correction of a short nose. The anterior enlargement of the septum can improve a flat and wide nasal dorsum as well as an underprojected tip.
- In this study, Asian nose had insufficient height of the septum in the dorsobasal direction and sometimes in the caudal-cranial direction and was corrected by the work on nasal septum by septal onlay graft using costal cartilage graft and columellar strut.
- Sagging (down-rotated nose): Karameşe et al.  described the down-rotated nose, as a result of too prominent anterior septal angle and adjacent caudal edge of the cartilaginous septum. It can be corrected by resecting cartilage and overlying mucosa of the anterior septal angle and the adjacent caudal edge.
- In this study, when managing it by the method of Karameşe et al. , there was residual down rotation, so it is recommended to use running spanning sutures technique and columellar strut.
- Over-rotated nose: Kopacheva-Barsova and Nikolovski  explained the causes of over-rotated nose by surgical or accidental trauma, or developmental in a child had destruction in two growth zones.
- In this study, one case only was resulting from overcorrection of acute nasolabial angle by overexcision of caudal edge of the septum (surgical trauma). It was corrected by septal extension graft.
- Pollybeak tip: the shape of the nose is similar to a parrot’s beak. Pollybeak occurs when the supratip projects farther than the tip defined points.
Allak and Park  explained the causes of the pollybeak tip by congenital or a result of managing the bony but undermanaging of the cartilaginous portion of a dorsal hump.
In this study, pollybeak deformity resulted from high anterior septal angle, and it managed by trimming of the anterior septal angle according to the cartilage dorsal lowering, combined with tip elevation and refining by transdomal sutures and columellar strut.
| Conclusion|| |
The DNS affects the aesthetic appearance of the nose, but not all types of deviations of the septum and not all parts of septum affect it. The bony part does not affect the shape of the nose. However, deviations that reach the dorsum of the nose or columella and in cartilaginous part of the septum surely affect the shape of the nose. Moreover, not only deviation affects the shape but also abnormal dimensions of the septum and types of angles affect it (even when the septum was straight).
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3], [Table 4]