24 Saddle Nose after Septoplasty or Trauma



10.1055/b-0035-121702

24 Saddle Nose after Septoplasty or Trauma


Saddling of the nasal dorsum may result from a septal perforation or nasal trauma. Both etiologies involve mechanical weakening of the anterior septal cartilage. Besides functional problems, cartilaginous deviation, or a perforated septum, postoperative saddle nose is the most important complication of septal surgery. Destruction of the supportive function of the anterior septum for the nasal dorsum leads to collapse of the cartilaginous nasal dorsum. Bony saddle nose, a hallmark of tertiary syphilis decades ago, has become rare today ( Fig. 24.1 ).

Fig. 24.1 Bony saddle nose deformity in tertiary syphilis.

There may be lateralization, spreading, or separation of the upper lateral cartilages, depending on the depth of the saddling. With depression of the dorsal septal border, an important tip support mechanism is compromised. This leads to collapse of the supratip area and anterior septal angle. The nasal tip becomes amorphous. The loss of tip support leads to cephalic rotation of the tip. The tip may even rotate downward if the anterior septal margin is lost. Cephalic rotation also leads to loss of tip projection. The nasolabial angle is blunted (> 110 degrees). The loss of structural support allows the caudal portions of the upper lateral cartilages to sag, deforming and dilating the internal nasal valve. The alar cartilages spread laterally, resulting in a wide and bulbous nasal tip. The special aspects of septal surgery in children are reviewed on p. 21. Fig. 24.2 , Fig. 24.3 , and Fig. 24.4 illustrate the three different pathogenic mechanisms of saddle nose deformity.

Fig. 24.2 (a) Cartilaginous saddle nose has resulted from cartilage loss (cartilage = blue) in the area indicated, with preservation of the anterior septal border. Note the collapse of the cartilaginous nasal dorsum and the cephalic tip rotation with loss of projection. (b) Typical changes in the nasal base with broadening of the nasal valve and compensatory hyper-plasia of the inferior turbinate.
Fig. 24.3 Cartilaginous saddle nose with destruction of the causal septal border. The lower columella is retracted upward, creating a hidden columella, and the alar-columellar complex is deformed.
Fig. 24.4 Posttraumatic saddle nose with an open roof, displacement of nasal bone fragments, and disruption of the bony and cartilaginous junction at the rhinion (keystone area) with an inverted V.


Case 28



Introduction


A 21-year-old woman presented with the concern of a marked change in nasal shape one year after sustaining nasal trauma.



Findings


Frontal view ( Fig. 24.5a ) shows a broadened nasal tip with a wide dorsum. Profile view ( Fig. 24.5b ) shows a postoperative saddle nose deformity with saddling in the supratip area, a loss of tip projection with cephalic rotation, and loss of structural support due to overresection. Oblique view ( Fig. 24.5c ) shows a hidden columella due to loss of the anterior septal cartilage.

Fig. 24.5 (a–c) Findings before septorhinoplasty. (d–f) Two years after revision rhinoplasty. (g) Surgical procedure, variant A: A columellar strut may be necessary in patients who lack tip projection. This was not necessary in the case shown. (h) Surgical procedure, variant B: Replacement of the anterior septum with conchal or rib cartilage. The upper lateral cartilages are fixed to the dorsal edge of the neoseptum, and the septal cartilage is fixed basally with a suture passed through the nasal spine.

Fig. 24.5d , Fig. 24.5e , and Fig. 24.5f show corresponding views 2 years after revision rhinoplasty.

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Jun 9, 2020 | Posted by in OTOLARYNGOLOGY | Comments Off on 24 Saddle Nose after Septoplasty or Trauma

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