Nasal Deformity: A ProfileRAJESH BHATIA & R. C. DENA

A total of 330 patients with nasal deformity were evaluated. Crooked nose has been found thecommonest nasal deformity (52 %). Other deformities included saddle nose (15%), hump nose (11%),tip deformities (3%) and miscellaneous deformities (15%). A profile of these defermities is beingpresented.

Rhinoplasty is increasingly be-coming popular. More and moreOtolaryngologists are involvednow a days in this practice. Aware-ness of the problem associatedwith nasal deformities is increasingamongst people and hence theincrease in number of patients withsuch problems seeking corrective-rhinoplastic surgery. As such atrend was observed in the Rhino-logy Clinic, studying the varioustypes of nasal defor mitiesandtheir associated functonal dis-orders in our own patientcommniity seen during the last4 years starting from 1980 in ourclinic. It is attempted to identifythe probem we face with thesepatients so that the magnitudeof the problem is known

Materials and Method: We evalua-ted a total of 1330 patients in ourRhinology clinic from Oct. 1980through June, 1984 (Table, I), ofthese, 373 patients (28%) had prob-lems related to nasal deformity.Whether the problem was pri-marily a cosmetic or a functionalone or a combination of both,were identified during historytaking and in clinical examination.History of trauma or other possibleaetiological factors of the defor-mity were evaluated. Reasons if

Rajesh Bhatia, Senior Resident,R. C. Deka, Asstt. Profersor.Department of Otorhinolaryngology,AIIMS, New Delhi-110 029.

Reprint Request toDr. Ramesh C. Deka, Dept. of ENT, AIIMSNew Delhi-110029.

AcknowledgementThe authors are grateful to Prof. S. K.

Kacker, Head of the Department of ENT,AIIMS, New Delhi, for his constantencouragement in preparing this com-munication.

cosmetic surgery was sought for,were .elecited. For the purposes ofdescription, we divided the prob-lem into 5 major categories (1)crooked or scoliotic-nose : Whenthe nasal dorsum was tilted orlateralised to either side in thebony and/or cartilagenous. partscausing external deformity (ii)Saddle nose whether in bony and/or cartilagenous parts (iii) Humpnose (bony or cartilagenous) (iv)Tip-deformity (v) Miscellaneousdeformities which include defor-mities of ala and collumella, andthose associated with skin andtissue loss.

TABLE

Showing number of patients withnasal deformity attending a specialityRhinology Clinic. *

Total No. ofnumber of patients

Year patients with nasaldeformity

(%)

1980 94 18 (19.1)(Oct.-Dec.)1981 248 46 (18.5)

1982 275 54 (19.6)

1983 350 107 (30.6)

1984 363 148 (40.8)(Jan.-June.)

Total 1330 373 (28.1)

*Rhinology clinic, Department of ENT,AIIMS, New Delhi.

Results and observations : A totalof 413 major nasal deformities,recorded in 373 patients com-prised the study (Table II). TheAge and Sex distribution are shownin Table III ft IV. Disability ofpatients with nasal deformity is

shown in Table V. Sexwise dis-tribution of disability showed thatmore female patients came forcosmetic problems (Table VI).Distribution of miscellaneousdeformities is shown in Table VII.Crooked-nose has been the com-monest type of deformity accoun-ting for 52%, followed by saddle-

nose (15%) and Hump-nose (11%).Tip deformities accounted for7% of all the patients with nasaldeformities. The commonest age ofpresentation was adolescenceand young adulthood. Patientsbetween 10-40 years of age com-prised 88%.About 9% of the pa-tients were below 10 years and 3%above 40 years. In young patients( 10 yrs.) the crooked nose wasthe commonest deformity (47%)(Table VIII), and deformities asso-ciated with cleft lip and palateconstituted the next group (18%).In elderly patients ( 40 yrs.) cutnose following surgery for malig-nancies of nasal dorsum formed25% and crooked-nose-deformitywas seen in 33%, (Table IX). Maleswere by far the most accountedgroup comprising 75% of thesepatients. This is perhaps becausemales, being outgoing populationattend hospitals more frequently inour country and also because theywere exposed to trauma moreoften which is the commonestaetiological factor for nasal defor-mity. About 33% of patients withnasal deformity attended the hos-pital solely because of cosmeticproblems, while 15% of the totalpatients had nasal deformity andwere not very concerned about itand they attended the hospitalprimarily for functional breathingproblems. Rest 52% of thesepatients with deformities had bothfunctional and cosmetic problems.Awareness for comsetic problem

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NASAL DEFORMITY : A PROFILE-BHATIA & DEKA

TABLE II

Showing distribution of major nasaldeformities* (

Nasal deformity (%) No.(%)

1. Crooked Nose 216 (52.3)

2. Saddle Nose 61 (14.8)

3. Hump Nose 44 (10.7)

4. Tip deformity 29 (7.0)

5. Miscellaneous 63 (15.3)

Total 413

*Total number of patients : 373

was more observed in female pa-tients (50%) as compared to thatin males (27%) (Table VI). About80% of these patients were un-married and many reported forcorrection prior to their marriagein order to have improved appe-arance of the face.

TABLE Ill

Showing distribution of Age in 373patients with nasal feformities

Years No. (%)

10 yrs. 34(9.1)

10-20 168 (45.1)

20-40 159 (42.6)

40 yrs. 12(3.2)

TABLE IV

Showing sex distribution in 373 caseswith nasal deformities.

Sex No. (%)

M 289 (77.5)

F 84 (22.5)

TABLE V

Showing distribution of disability in373 patients with nasal deformity.

Disability No. (%)

i) Functional 55 (14.7)

ii) Cosmetic 120 (32.2)

iii) Combination of 198 (53.1)both i) & ii)

TABLE VI

Showing distribution of disabilityin 373 patients with nasal deformityaccording to sex.

Disability Males,No. (%)

i) Functional 48 (16.6)

ii) Cosmetic 78 (26.9)

iii) Combination 163 (56.4)of (i) and (ii)

Total 289

TABLE VII

S.No. Deformity

No.(%)

1. Cut Nose

15 (3.6)Post traumatic (10)Post surgery (5)

2. Broad Nose

11 (2.7)

3. Deformities of

11 (2.7)collumella & Ala

4. Vestibular stenosis

8 (1.9)Post traumatic (6)Post NasogastricIntubation (2)

5. Nasal deformity with

7 (1.7)cleft lip and palate

6. Scar Nose

5 (1.2)

7. Narrow Nose

3 (0.7)

8. Thickened lateral

3 (0.7)nasal wall

Total

63 (5.3)

TABLE VIII

Nasal deformities in Paediatricpatients ( 10 yrs.)

S.No. Nasal deformity No.(%)

1. Crooked Nose 16 (47.1)

2. Cleft lip Ft Palate 6 (17.6)

3. Tip deformity 3 (8.8)

4. Congenital Alar 3 (8.8)deformity

5. Vestibular stenosis 2(5.9)

6. Scar Nose 2 (5.9)

7. Saddle Nose 7 (2.9)

8. Wide bridge 1 (2.9)

Total 34

TABLE IX

Nasal deformity in Elderly Patients( 40 yrs.)

S.No. Nasal deformity No.(%)

1. Crooked Nose 4 (33.3)

2. Cut Nose 3 (25.0)(Post Surgical)

Discussion : Clinical profiles ofvarious deformities are beingdiscussed as follows :-

Crooked nose : Crooked nose orscoliotic nose or lateralisationdeformity of the nose was thecommonest deformity (52.3%).They are of three types (a) classicalcrooked nose involving the septum,bony dorsum and the cartilaginousdorsum, (b) septum, bony andcartilagenous dorsum lateralisingto one side known as lateralisationdeformity, (c) bony dorsum straightbut the cartilage dorsum, and carti-lagenous septum are lateralised.About 92% of these patients alsohad DNS, more commonly to theleft side. Classical crooked-noseto left with left sided DNS wasthe commonest type observed, ofcases, revealed history of traumaCrooked-nose of the cartilagenousdorsum was always associated withDNS (100%). History of some formof trauma was present in 48% ofthese cases. Sexwise males hadcrooked nose more commonly dueto trauma (47%) than females(23%) had.

Saddle Nose : Saddle-nose ordepressed nasal dorsum con-stituted about 15%. It was un-commonly seen at the extremes ofages. About 94 percent of thesepatients were between 10-40 yearsof age at presentation. Male :Female ratio was 4 : 1. The com-monest aetiologic factors wasaccidental trauma (56%), it wasfollowed by SMR (20%) and

Females,No. (%)

7 (8.3)

42 (5.0)

35 (41.7)

3. Saddle Nose 2 (16.7)

84 4. Tip deformity 2(16.7)

5. Thickened Dorsum 1 (8.3)

96 Indian Journal of Otolaryngology, Volume 37, No. 3, September, 1985

NASAL DEFORMITY : A PROFILE—BHATIA & DEKA

septal abscess (8%). Leprosy,syphilis and tuberculosis accoun-ted for a few occasional cases(3%), while the aetiology was notknow clearly in 13%. About 35%patients were concerned for cos-metic problem only while the rest65% had some associated disor-ders of function, especially due toassociated DNS (42%) and narrow-ing of valve areas and at times dueto septal perforation. Supra-tip depression in the cartilaginousdorsum, followed most commonlyduo to SMR (50%), accidentaltrauma (42%) and s9ptal abscess(8%). Bony depression of nasaldorsum was associated with acci-dental trauma in 68%, septalabscess in 8%. History of congeni-tal deformity was present in 3%,most commonly associated withcleft lip and palate.

Hump Nose : Hump deformity ofnose (11%) was associated withother deformities of nose such ascrooked nose and/or DNS. How-ever, pure hump-deformity acoun-ted for 6% of all major nasal defor-mities. It was more commonly seenin males (80%) and they presen-ted between 10-40 years of age.Some form of trauma was causedin about one-fourth of the cases;

followed by bifid tip (10%), re-tracted tip (7%) and drooping tip(3%). Majority of the patients werebetween 10-40 years of age (77%)although younger (8%) as wellas elderly patients (15%) alsoexhibited such deformities. About85% of patients were males. Mostof these patients presented forcosmetic problems.

Miscellaneous deformities : Otherdeformities of nose included cutnose (3.6%), broad nose (2.7%),columellar and alardeformis (27%),(2.7%), vestibular stenosis (1.9%)and nasal deformities associatedwith cleft lip and palate (1.7%).Cut nose for the females was mostcommonly due to chopping offnose by the husband for reasons ofinfidelity. It is a traditional formof punishment offered to the vic-tims of infidelity in a particularcommunity, in our country. Othercause includes surgical ablation fornasal malignancy.

Comments : Rhinoplasty is amixture of science and art re-quiring multifaceted and complexprocedures to improve cosmeticappearance as well as functionaldisorder. An attempt has been

Fig. 1 Left-(Top & Bottom)—Photographs showing Crooked nose—deformit' intwo patients—One (top) was dua to trauma and the other (bottom) was ofcongenital origin. This latter patient also had velopharyngeal incompetance.Right—Two patients (male & female) having the hump—deformity; both wereof congenital origin and the male had also D.N.S.

rest were parhaps of congenitalorigin.

Tip Deformity : Amongst the tipdeformities (7.0%) bulbus tip wasthe commonest deformity (80%)

Fig. 2 Left—Photograph (Top) of a patient who developed Saddle-nose followingtrauma to the nose and the other (below) had history of infection and abscess-formation leading to such nasal-drosum collapse.

Right—A 20 year old female having bifid nose deformity of congenital origin.

Indian Journal of Otolaryngology, Volume 37, No. 3, September, 1985 97

NASAL DEFORMITY : A PROFILE-BHATIA & DEKA

made in this communication toidentify the profiles of the nasaldeformities in the patients atten-ding our rhinology clinic. ENT Sur-geons must be aware of thespectrum and the magnitude ofproblem associated with the pa-tients of various nasal deformities.Crooked nose being the com-mosent deformity,it bestows uponENT Surgeons to be fully aware ofthe various osteotomies and theirapplications in individual cases

of such deformities as describedby Wright (1975), Sood (1977,1981), and Deka (1985). Correc-tion of saddle nose has been des-cribed well by Krause (1975) andSood (1979). Technique of hump-nose reduction has been des-cribed by Stoog (1966) and Wright(1967). Tip deformities, thoughnot very common require meticu-lous care and precision on thepart of a surgeon (Berman, 1975).A surgeon dealing with rhino-

plasty work encounters cases ofcut nose requiring use of localflaps and a knowledge in thisfield is essential (Hunter, 1972;Deka, 1985).

Finally, if the patient awarenesscontinues to grow as observed,a much more dedicated applicationand expertise will be required todeal with the volume of clinical-work related to nasal deformities,in our community.

References

1. Berman, W. E., (1975). Surgery ofthe nasal tip. Otolaryngological cli-nics of North America. Vol. 8, No. 3,563.

2. Deka, R. C. (1985). Hump-Reduc-tion Rhinoplasty Indian Journal ofSur ery-(in press)

3. Gunter, J. P., (1972). Nasal recon-struction using pedicle skin flaps.Otolaryngological clinics of NorthAmerica. Vol.5, No. 3, 457.

4. Krause, C. J. (1975). AugmentationRhinoplasty. Oto/aryngological cli-nics of North America. Vol. 8, No. 3,743.

5. Sood, V. P. (1977). Rhinoplasty forthe external nasal deformity. IndianJournal of Otolaryngology, 29, 119.

6. Sood, V. P. (1979). AugmentationRhinoplasty for saddle nose. IndianJournal of Otolaryngology, 31, 7.

7. Sood, V. P. (1981). Correction ofcrooked nose. Bihar Journal ofOtolaryngology, 2, 3.

8. Stoog, T. (1966). A method of humpreduction in Rhinoplasty. A techniquefor preservation of the nasal root.Archives of Otolaryngology, 92, 283.

9. Trent, W. S. (1975). Septorhinoplasty,Otolaryngological clinics of NorthAmrica. Vol. 8. No. 3, 645.

10. Wright, W. K. (1967). Study on humpremoval in Rhinoplasty, Laryngos-cope, 77, 508.

11. Wright, W. K. (1975). Surgery of thebony and cartilagenous dorsum, Oto-laryngo%pica/ clinics of NorthAmerica.Vol. 8, No. 3, 575.

98 Indian ,Journal of Otolaryngology, Volume 37, No. 3, September, 1985