Chapter Contents
Pathology 304
Patient Assessment 309
Radiology 312
Surgical Treatment of the Deviated Nose 313
Correction of Deviated Nasal Bones 313
Septal Tilt 315
Correction of Anteroposterior C-shaped Deviation 320
C-shaped Cephalocaudal Deviation 324
S-shaped Anteroposterior Deviation 328
S-shaped Cephalocaudal Deviation 328
Localized Deviation and Spurs 328
Use of Stents 335
Correction of Deviated Caudal Dorsum 335
Correction of Deviated Nasal Base 335
The Role of Turbinates 343
Turbinectomy 343
Postoperative Care 346
Secondary Procedures 346
Online Contents
Animations
Trimming the Upper Lateral Cartilages too Early Results, Residual Excess on One Side and Shortage on the Other Animation 17.1
Correcting Septal Tilt Animation 17.2
Osteotomy to Reposition a Deviated Nasal Spine Animation 17.3
Correcting Septal Tilt to the Right Internally and to the Left Externally Animation 17.4
Release of Tension by Creating a Swinging-Door-Type Movement Usually Eliminates a C-shaped Deviation Animation 17.5
Placing Spreader Grafts Controls Anterior Curvature Animation 17.6
Demonstration of the Surgical Steps on a Patient with C-shaped Anteroposterior Deviation Animation 17.7
Illustration Showing Correction of a C-shaped Cephalocaudal Deviation Animation 17.8
Demonstration of the Surgical Steps on a Patient with a C-shaped Cephalocaudal Deviation Animation 17.9
Illustration Demonstrating Correction of an S-shaped Anteroposterior Deviation Animation 17.10
Demonstration of the Surgical Steps on a Patient with an S-shaped Anteroposterior Deviation Animation 17.11
Illustration Showing Correction of an S-shaped Cephalocaudal Deviation Animation 17.12
Demonstration of the Surgical Steps on a Patient with an S-shaped Cephalocaudal Deviation Animation 17.13
Placing a Septal Rotation Suture Animation 17.14
Correcting Caudal Deviation of the Nose Animation 17.15
Reducing the Projection of the Lower Lateral Cartilage on One Side Animation 17.16
Repositioning a Deviated Nasal Base Animation 17.17
Correcting Tip Deviation and Adjusting the Lower Lateral Projection Animation 17.18
Pearls
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Commonly, the deviated nose and septum are associated with other conditions such as sinus headaches, frequent sinus infections and migraine headaches.
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Nasal deviation and valvular dysfunction following facial paralysis offers the best evidence regarding the role of the soft tissues in nasal symmetry and valve function.
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A longstanding shift of the midline structures cannot be simply corrected with an osteotomy and forceful repositioning. It requires component separation and realignment of all of the structures individually, including the nasal bones, the septum and the upper lateral cartilages.
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Mid-vault deviation consistently accompanies anterior, and commonly, mid and posterior septal deviation.
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Of the six classes of septal deviation, the most common is the septal tilt in which the septum itself has no significant underlying curvature but it is tilted to one side because the caudal septum is dislodged to one side of the vomer bone (often the left side).
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The C-shaped anteroposterior deviation is the second most common type of septal deviation.
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A persistent unilateral obstruction of the airway is a reliable indicator of a mechanical airway compromise.
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A negative history of airway obstruction is not a reliable indication of a patent airway since the patients may not have a basis for comparison.
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Many female patients with nasal deviation pluck their eyebrows differentially to camouflage the nasal asymmetry, which can be misleading. On these patients, the mid-eyebrow point should not be used as the upper face midline.
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In patients who have frequent sinus headaches, sinus infections, or migraine headaches, a CT scan may disclose pathology such as septal deviation, sinusitis, concha bullosa, septa bullosa, contact points and Haller’s cell.
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A medial deviation of the nasal bone requires an outfracture of the bone that will be supported with an extended spreader graft to avoid medial shift of the bone while it is healing.
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A longstanding deviation of the anterior nose will require separation of the upper lateral cartilages from the midline and repositioning.
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A cardinal step in correction of most deviations, especially tilt, is disengagement of the dislodged caudal portion of the retained alar strut from the vomerine groove and anterior nasal spine, removal of the redundant, overlapping cartilage and repositioning and fixation to the nasal spine periosteum, as long as one is confident that the anterior nasal spine is positioned in the midline.
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If the anterior nasal spine is deviated, it has to be osteotomized and repositioned.
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Components of correction of anteroposterior C-shaped deviation include removal of the posterocephalic portion of the septum and the deviated portion of the perpendicular plate and vomer bone, repositioning of the posterocaudal septum, and rarely, scoring of the septum and placement of splints on either side of the septum.
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Correction of C-shaped cephalocaudal deviation requires removal of the posterocephalic portion of the septum, release of caudal tension and repositioning the L-frame, scoring the concave side if release of tension would not correct the deviation.
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Whenever the septum is scored, application of extramucosal stents is necessary to control and maintain the septum straight while it is healing.
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For correction of S-shaped deviation, the posterocephalic portion of the septum is removed and the caudal portion of the L-frame is repositioned, the concave side is scored, if necessary, and extramural splits and spreader grafts are applied.
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If an inadvertent tear in the mucoperichondrium is unilateral, it will not be consequential. If the tear is bilateral but the perforations are not apposing, the mucosa may still heal without persistent perforation. When the tears are apposing, a straight piece of septal cartilage or perpendicular plate is replaced and the extramural stents are applied for two to three weeks.
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The remaining caudal dorsal deviation can be corrected using a septal rotation suture. This is a horizontal mattress suture placed through the upper lateral cartilages and the septum more cephalad on the side that the structures will be rotated towards.
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A deviated caudal nose is often associated with disparity in the length of the lower lateral cartilage. Depending on the tip projection, one has to either elongate the short lower lateral cartilage or shorten the long side to rotate the tip to the midline.
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The notion that the turbinates may shrink after correction of the deviated septum is ill-conceived and illogical. Rather than shrinking, the enlarged turbinates may shift the septum off the midline.
One of the most frustrating, and at the same time, most rewarding aspects of rhinoplasty is dealing with the deviated nose. Almost invariably, a deviated nose is synonymous with some degree of nasal dysfunction. The magnitude of deviation governs the intensity of the symptoms in most patients. However, on rare occasions, a patient with a significant deviation of the nose may have minimal or no symptoms, and the reverse may also be true: a patient with minimal deviation may have a significant amount of nasal airway compromise. Commonly, the deviated nose and septum are associated with other conditions such as sinus headaches, frequent sinus infections, and migraine headaches, the recognition of which can lead to proper management and more gratifying outcomes. Residual or persistent deviation is often related to a failure to recognize the full extent of the structural deviation. Most deviations involve several structures of the nose and if one fails to correct all the abnormalities, the outcome is often disappointing. Therefore, it is essential to conduct a circumspect examination of the entire face, the external nasal frame, and the internal nasal structures.
Pathology
The soft tissue envelope with its underlying perinasal musculature plays a major role in maintaining the symmetry and patency of the valvular mechanism. Nasal deviation and valvular dysfunction following facial paralysis offers the best evidence regarding the role of the soft tissues in nasal symmetry and valve function. The perinasal musculature was discussed in Chapter 1 .
The septum constitutes the main central support for the nose, which is composed of the perpendicular plate, the quadrangular cartilage and the vomer bone (see Figure 1.17 in Chapter 1 ). The perpendicular plate of the ethmoid is in continuity with the posterior edge of the quadrangular cartilage and both structures are aligned caudally with the vomer. The most anterocaudal portion of the septal cartilage also rests on the maxillary crest in a tongue-and-groove relationship. This point of articulation is unique in that the perichondrium of the cartilage is only partially contiguous with the periosteum of the crest, allowing a decussation of fibers that joins the contralateral perichondrium. This configuration can make a submucoperichondrial dissection tedious. Starting the dissection from the posterior caudal septum and continuing it in the anterior direction may overcome the difficulty. This relationship between the cartilage and the bone renders this portion of the septum susceptible to post-traumatic displacement of the cartilage from the groove of the crest, correction of which is paramount for the successful straightening of the septum and consequently the external nose.
The area of overlap at the junction between the cephalic upper lateral cartilages and the nasal bones, which makes up the keystone area, is characterized by a firm adherence between these structures. Trauma to the nasal bones can shift this entire unit. A longstanding shift of the midline structures cannot be simply corrected with an osteotomy and forceful repositioning. It requires component separation and realignment of all the structures individually, including the nasal bones, the septum, and the upper lateral cartilages.
Adjustment of the size of the turbinates plays a cardinal role in the restoration of nasal function following correction of nasal deviation. The inferior turbinate occupies a large portion of the nasal airway and can account for up to two-thirds of the total airway resistance. The turbinates are covered with an erectile mucosal tissue composed of pseudostratified ciliated columnar epithelium. The submucosa contains many seromucinous glands and vascular channels containing cavernous sinusoids. These channels are under the influence of the autonomic nervous system and thus serve as the end target for decongestant medication. The sympathetic system regulates the resistance vessels (and therefore blood flow) and the parasympathetic system regulates the capacitance vessels (and therefore blood volume) of the nasal mucosa. The submucosa also contains large numbers of mast cells, eosinophils, plasma cells, lymphocytes, and macrophages. Thus, chronic inflammation secondary to stimulation of these abundant proinflammatory cellular constituents can lead to fibrous deposition and chronic hypertrophy of the turbinate. Long standing deviation of the septum, especially if it occurs at an early age, results in enlargement of the inferior and/or middle turbinate facing the concave side of the septum ( Figure 17.1 ).
The internal nasal valve accounts for approximately 50% of the total airway resistance and is the narrowest segment of the nasal airway. It is formed by the angle between the junction of the nasal septum and the caudal margin of the upper lateral cartilage and is typically 10–15°, as mentioned in earlier chapters (see Figure 1.13 in Chapter 1 ).
The importance of the nasal valves in nasal airflow cannot be overstated and has been studied extensively. The internal nasal valve is a crucial regulator of nasal airflow dynamics and should be preserved and/or reconstructed during rhinoplasty. Injury and destabilization of this complex, by either surgery or trauma, may result in collapse and subsequent nasal airway obstruction. The external nasal valve, which serves as the entrance to the nose, is formed by the caudal edge of the lateral crus of the lower lateral cartilage, the soft tissue alae, the membranous septum, and the sill of the nostril (see Figure 1.13 in Chapter 1 ). This is an occasional site of obstruction secondary to extrinsic factors, such as foreign bodies, or intrinsic factors, such as weak or collapsed lower lateral cartilages, a loss of vestibular skin, or cicatricial narrowing. Normal function of this valve depends on the structural integrity of the lower lateral cartilages, the perinasal musculature, and adequate soft tissue coverage. Functional compromise can occur with encroachment of the nasal spine, and especially the footplates, into the nostril opening. Architecturally weak lateral crura further compound the effects of a widened columella. Other causes for external valve collapse include facial nerve palsy, pinched alar deformity, and postsurgical vestibular stenosis secondary to synechiae and over-resection of the lower lateral cartilages.
The septum and the nasal bones control the direction of the nose. Thus, deviation of the nose can result from misalignment of one or the other, or a combination of both. Often, the nasal bones follow the direction of the deviated septum. However, these structures may move independently. Midvault deviation consistently accompanies at least anterior and commonly mid- and posterior septal deviation. Deviation of the lower nose may involve the caudal septum, anterior nasal spine, and lower lateral cartilages. Previous studies by the author’s team and others have detailed and categorized the types of septal deviation.
There are six classes of septal deviation. The most common type is a septal tilt, in which the septum itself has no significant underlying curvature but is tilted to one side because the caudal septum is dislodged to one side of the vomer bone ( Figure 17.2 ). In most cases of septal tilt, the internal dislodgement of the septum is to the left and the external deviation of the nose is to the right. This is usually accompanied by an enlargement of the inferior turbinate ipsilateral to the external deviation.
C-shaped anteroposterior deviation is usually associated with deviation of the vomer plate. External reflection of the anteroposterior C deviation is often similar to the septal tilt ( Figure 17.3 ). In addition to the enlargement of the inferior turbinate, the middle turbinate is often enlarged as well.
C-shaped cephalocaudal deviation presents externally as a curved appearance of the nasal dorsum. The most common form of this deviation is the reverse C with the curve facing the patient’s right ( Figure 17.4 ). The opposing inferior, and often the middle, turbinate is enlarged.
S-shaped anteroposterior deviation is defined by two opposite curvatures in continuity in the anteroposterior direction ( Figure 17.5 ). Externally, the anteroposterior deviation will present with a shift of the nose to the left or right. Rarely, the anterior portion of the nose may look totally straight.
S-shaped cephalocaudal deviation is similar to the previous type except that the curvatures are in the cephalocaudal direction ( Figure 17.6 ). Inferior and middle turbinate enlargement is common with both types of S-shaped deviations. The external nose follows the pattern of the septal deviation.
The last type of septal deviation is a localized deviation or spur. This is a purely functional problem and has no translation to the external shape of the nose ( Figure 17.7 ). Turbinate enlargement is not common with this type of deviation.
Patient Assessment
A detailed patient history of nasal trauma, previous nasal surgery, airway complaints, and allergies is obtained. Cyclical nose obstruction is a physiological change. A persistent unilateral obstruction of the airway is a more reliable indicator of mechanical airway compromise. On the other hand, a negative history of airway obstruction is not a reliable indication of a patent airway, since the patient may not have a basis for comparison. If the obstructive symptoms occur during quiet and deep inspiration, this indicates a fixed obstruction such as an enlarged turbinate, a septal deviation, or a mass. However, obstruction that occurs only during deep inspiration may indicate an incompetent internal or external nose valve.
Attention to detail and careful observation are vital in order to garner the critical information necessary to arrive at the correct diagnosis and an effective surgical plan. Observation of the external nose and face should include attention to oral or nasal breathing. Mouth-breathing can be continuous or intermittent. Additionally, the face should be assessed for overall symmetry, canting of the plane of occlusion, and alignment of the nose with the rest of the facial structures ( Figure 17.8 ). The chin position should be noted in relation to the upper face midline, the upper and lower lips. and the midline of the upper and the lower incisors. The midline should be set at the intercanthal line rather than the intereyebrow plane. Many female patients with nasal deviation pluck their eyebrows differentially to camouflage the nasal asymmetry, which can be misleading ( Figure 17.9 ). On these patients, the mid-eyebrow point should not be used as the upper face midline. Examination of the oral cavity may reveal a very high and narrow palatal arch that encroaches on the nasal airway. Such patients commonly have a very constricted nasal airway and require special care to maintain and perhaps widen it ( Figure 17.10 ).
Facial nerve function is also assessed, since paralysis of the perinasal muscles can cause nasal airway obstruction. The nose is then observed zone by zone for deviated structures, including the nasal bones, the anterior septum, the upper and lower cartilages, and the lower lateral cartilages, similarly to the procedure described in Chapter 2 . A basilar view with the head tilted back may disclose columella, tip, footplate, nostril, and alar base asymmetry. An overhead view is the most helpful view for detection of external nasal deviation.
Palpation is critical in assessing the three-dimensional frame of the nose. This portion of the examination should include palpation of the nasal bones, upper lateral, and lower lateral cartilages, as well as the membranous septum, the caudal cartilaginous septum, and the anterior nasal spine. Palpation and percussion over the frontal, ethmoid, and maxillary sinuses is performed to elicit tenderness that may be indicative of inflammation of the underlying structures and sinuses.
The patient’s nostril is occluded one side at a time and the patient is asked to inhale normally and then deeply. If nasal valve incompetence is suspected, the Cottle test is employed. While the patient breathes quietly, the nostril is supported with a nasal speculum or the cheek is retracted laterally to open the nasal valve. If breathing is improved, this represents a positive Cottle test and is valid evidence of nasal valve incompetence. Another maneuver allowing independent evaluation of the external and internal nasal valves is simply to use a cotton-tip applicator to stent the airway during light and deep inspiration, as discussed in Chapter 2 .
The internal nose is examined for detection of septal deviation, enlarged turbinates, synechiae, perforation, spurs, and contact between the turbinates and the septum. Any crusting, purulence, ulceration, or presence of polyps should be noted. The color and size of the turbinates are also documented, as a pale turbinate mucosa may indicate allergy, whereas erythematous mucosa may indicate an infection or inflammatory process, implying rhinitis of some sort.
The above examination maneuvers should be repeated before and after vasoconstriction of the nasal mucosa using 0.25% phenylephrine or 1% ephedrine sulfate. These agents can be delivered via an aerosolized misting system or topically with cottonoid pledgets. Posterior rhinoscopy is often helpful in symptomatic patients. Visualization of the posterior nasal airway is best achieved using a 0° or 30° nasal endoscope.
Life-sized photographic and cephalometric analysis, as described above, is used to further confirm the findings of the physical examination.
Radiology
In patients who have frequent sinus headaches, sinus infections, or migraine headaches, review of a computed tomography scan may prove extremely useful in detection of pathology that cannot be visualized during physical examination such as sinusitis, concha bullosa, septa bullosa, Haller’s cell and contact points.
Surgical Treatment of the Deviated Nose
Successful correction of a deviated nose requires full recognition of the existing pathology and complete elimination of deviation from all components of the nose. The deviation can be in the nasal bones, the upper lateral cartilages, the caudal dorsum, or the basal unit of the nose. Often a combination of deviations coexist.
Correction of Deviated Nasal Bones
The deviation in the nasal bone can be unilateral or bilateral. Unilateral deviation is corrected with an onlay graft if it is not of functional consequence. This is accomplished using a layer of intact septal cartilage graft or a thin layer of diced cartilage or soft tissue graft. The outcome of the former is more predictable.
Under general anesthesia, the face is prepped and nasal vasoconstriction is achieved using the double injection method described in Chapter 4 . An intercartilaginous incision is made and the target nasal bone is exposed. The periosteum is elevated using a Joseph’s periosteal elevator in a limited fashion. Septal or conchal cartilage graft in the form of a single or double layer gently crushed, depending on the degree of the nasal bone shift, diced cartilage, or a layer of soft tissue, such as dermis or fascia graft, is applied in the subperiosteal plane and molded in place. The incision is repaired loosely to allow for drainage.
Usually, however, a visible shift of the nasal bone is associated with medial transposition of the upper lateral cartilages, which compromises the ipsilateral internal valve function. With this scenario, a unilateral outfracture of the nasal bone produces a better functional and aesthetic outcome. Through a small vestibular incision at the pyriform aperture, the periosteum is elevated using a Joseph’s periosteal elevator. A low-to-low osteotomy is performed and the nasal bone is outfractured. Often, the bone union after the previous fracture is incomplete and the osteotomy can readily be completed as long as the osteotome is advanced through the old osteotomy site. To avoid return of the nasal bone to its previous position, placement of a spreader graft can be very useful. An incision about 3 mm long is made in the mucoperichondrium immediately caudal to the junction of the upper lateral cartilage and the septum anteroposteriorly. The septal elevator is used to create a pocket large enough to accommodate the spreader graft. The graft is inserted between the septum and the upper lateral cartilage and advanced under the nasal bone. Additionally, a piece of folded Adaptic™ or Surgicel™ saturated in bacitracin ointment is placed between the nasal bone and the septum and kept in position for at least 1 week. During this time, the patient is maintained on systemic antibiotics.
Bilateral nasal bone deviation can only be corrected with bilateral osteotomy and repositioning of the deviated nasal bones. This may require a septoplasty as well. If, in addition to the deviation of the nasal bones, the midvault is deviated, this mandates a septoplasty, along with separation of the upper lateral cartilages from the septum, which is discussed in detail below. Depending on the type and nature of the deviation, the nasal bones are either osteotomized on each side simultaneously or both nasal bones are osteotomized laterally and cephalically without a medial osteotomy and are shifted together as a single unit. This osteotomy is technically challenging and seldom corrects the deviation effectively. Most deviated noses can be effectively corrected using the bilateral independent controlled osteotomy described in Chapter 4 , along with septoplasty.
Deviation of the midvault is synonymous with deviation of the septum. This type of deviation can rarely be corrected simply with a camouflage graft. In the majority of cases, a thorough correction of septal deviation is necessary to correct the midvault deviation. Additionally, the upper lateral cartilages have to be separated from the septum and differentially trimmed after repositioning of the septum to the midline and completion of the osteotomies ( Figure 17.11 ; Animation 17.1).
