Diagnosis and Management of Common Presentations of Posttraumatic Nasal Deformity: A Narrative Review

Abstract

Background: 

Posttraumatic nasal deformity (PTND) is a surgical challenge for the otolaryngologist and plastic surgeon. Various classifications and management algorithms have been proposed without reaching much consensus in terms of definition and management.

Methods: 

We present a narrative review aimed to define PTND and consolidate current knowledge regarding its diagnosis, subtypes, and treatment options.

Results: 

This report is a clinical overview of PTND. We also review recent studies that characterize different osteotomy approaches and techniques used for patients with PTND.

Conclusions: 

By providing a summary of the main challenges for PTND, we aim to add context to its variable presentation. We hope this broad overview will reinforce more effective communication between providers and promote patient understanding in order to ensure favorable long-term outcomes.

Takeaways

Question: How do we define posttraumatic nasal deformity? What are the available evidence-based methods of management for this condition?

Findings: By providing a narrative review of the core challenges for posttraumatic nasal deformity, we aim to reinforce more effective communication between providers and promote patient understanding.

Meaning: We summarize optimal treatment strategies in order to ensure favorable outcomes for patients with posttraumatic nasal deformity.

INTRODUCTION

The nose holds a central location on the human face. Its prominence from the relatively flat facial features that surround it makes it particularly vulnerable to trauma. After traumatic injury, the nose is prone to the establishment of deformities due to its composite osseocartilaginous structure and the complex anatomic and physiologic interactions among its subsites. The nasal bones are the most frequently fractured bones in the facial skeleton and are typically managed with primary treatment immediately or within a few days after trauma.^1–3 Various classifications and management algorithms have been proposed without reaching consensus in the definition or the management of posttraumatic nasal deformity (PTND).^4–7 The present report aims to define the postoperative complications that can occur in the traumatized nose and consolidate the current knowledge in the diagnosis and management of such changes.

MANAGEMENT OF NASAL BONE FRACTURES

The initial management of nasal bone fractures remains controversial. These fractures encompass a wide range of variation, including simple, unilateral or bilateral, displaced or nondisplaced, and severely comminuted. Classically, nasal bone fractures are managed with observation alone or closed nasal bone reduction. The decision for intervention is generally guided by two main indications: new-onset nasal airway obstruction (NAO) and postinjury cosmetic concerns. The procedure is performed once local edema subsides, usually within 7–10 days. Alternatively, immediate postinjury nasal bone reduction can be performed before the development of local edema, ordinarily within 6–8 hours from injury, under local anesthesia in the emergency room setting. In this initial presentation, treatment decisions must focus on preventing long-term aesthetic and functional complications of the acute injury.^8,9 Many treatment algorithms have therefore been proposed to guide the classification and management of nasal fractures.^10–13 We prefer the comprehensive surgical algorithm for traumatic nasal deformities developed and validated by Bayram et al, which addresses deformities in both bony and cartilaginous structures (Fig. 1).¹⁴

Fig. 1.: Comprehensive surgical algorithm for traumatic nasal deformities.¹⁴ Reprinted with permission from Bayram Y, Yapici AK. Late correction of traumatic nasal deformities: a surgical algorithm and experience in 120 patients. Aesthetic Surgery Journal. 2018; NP182-NP195.

Patients with persistent NAO after initial management are typically addressed with functional nasal surgery after recovering from the initial injury. “Corrective” or “subsequent” septorhinoplasty are terms previously used in the literature for the procedures that occur at least 6 months after initial injury to allow for complete healing of the traumatized nose.

In a large, population-based analysis of 78,474 US patients with isolated nasal bone fractures, the rates of subsequent septorhinoplasty were between 1.6% and 3.6% depending on the initial management, including observation alone, closed reduction, or open reduction.¹⁵ Although the largest of its kind, this study is inherently limited by its insurance claims database. In addition, septorhinoplasty is not the only option in the surgeon’s armamentarium; a variety of surgical techniques can be used to address the posttraumatic nose, corresponding to alternative billing codes not accounted for in the study. Therefore, the true rate of subsequent functional nasal surgery in patients with nasal bone fractures is underestimated, necessitating further prospective study in the field.

CONTROVERSIES IN NOMENCLATURE

The terms “posttraumatic nasal deformity,” “traumatic nose,” and “posttraumatic nose” have been used interchangeably in the plastic surgery literature.^14,16–18 Like other aspects of nasal surgery, the plethora of used terms and lack of consensus on standardized nomenclature may hinder education and interactions among surgeons.¹⁹

In the present article, we accept posttraumatic nasal deformity (PTND) as the umbrella term for the unfavorable alterations in the nasal form that results from healing changes due to traumatic injury.

The “crooked nose” and “saddle nose” have been previously described as remarkably challenging conditions within the realm of PTNDs.¹⁷ Clinically, these are typically managed with arduous surgical procedures that require extensive clinical expertise. The severe deformity of the nasal septum in the crooked nose is most often associated with deformities of the osseous nasal vault. Furthermore, a nasal septum perforation can be diagnosed as an isolated finding or in combination with other deformities in the posttraumatic nose. Dynamic collapse of the lateral nasal wall can also present a long-term sequela of nasal trauma affecting the anatomic areas of the internal and the external nasal valves. Finally, similar to postoperative iatrogenic deformities, uncontrolled scarring can result in frank cicatricial stenosis of critical areas within the nasal airway.

THE CROOKED NOSE

The posttraumatic deviated nose is exceedingly complex. It can be considered the most classical paradigm of the unity of form and function in the nose. Regardless of a functional or aesthetic chief complaint, we counsel these patients that the distorted appearance and functional deficits are intertwined and should be managed as one entity.

In PTND, a detailed clinical history includes the mechanism and timeline of past nasal trauma. Physical examination of the crooked nose begins with inspection of the upper, middle, and lower thirds of the nose in the frontal view.^20,21 Nasal endoscopy is performed during the encounter in order to assess other factors that contribute to NAO, such as nasal polyps, synechiae, nasal cavity inflammation, and sinusitis. During nasal endoscopy, attention is given to the internal nasal valves and photographic documentation is obtained. Preoperative computerized tomography scan is always helpful in these patients. A noncontrast maxillofacial computed tomography is typically ordered for surgical planning and to rule out chronic sinusitis, which would require separate management.

Additionally, the nasal valves are examined during normal breathing and forceful inspiration. An unrecognized dynamic nasal valve collapse may compromise surgical outcomes. The latter is often encountered in PTND as a sequela of longstanding increased negative pressure to the nasal sidewall due to posttraumatic structural alteration.

PTND of the upper third of the nose typically requires osteotomy. Various techniques and surgical approaches are used for the osteotomy depending on the severity of the deviation.²² The nomenclature, approach, and technique vary among surgeons, but the established classification includes medial, intermediate, and lateral depending on the path of the osteotomy through the nasomaxillary complex (Fig. 2A). Often the challenging PTND cases involving the bony vault will require more aggressive techniques. These may include combinations of a lateral type of osteotomy with a medial one and occasionally paramedian osteotomies. We prefer use of double-level osteotomies (low to low/high to high) connected to a transverse osteomy (Fig. 2B). (See Video [online], which displays an overview of the double-level osteotomy approach in management of severe posttraumatic nasal deformity.) This aggressive manipulation of the bony vault harbors risks of destabilizing the nasal bones and may create undesirable arrangement of the bony fragments. Often the results of the mobilization of the nasal bones can be frustrating, failing to balance the osseous deformity.

Fig. 2.: Surgical techniques for osteotomies. A, Schematic representation of medial (a), intermediate (b), and lateral (c) osteotomies. B, Schematic representation of “double-level” osteotomy approach combining low-to-low, “nasal-bone,” and transverse osteotomies.

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Piezosurgery, which uses piezo-electric ultrasonic vibrations, was introduced to perform more precise osteotomies in rhinoplasty in 2007, and has become an increasingly mainstream approach over the last 5 years.²³ Recent investigations and meta-analyses support its benefits in resulting in lower amounts of bone gap, comminuted fractures, and nasal mucosal damage as compared with conventional osteotomies.^24–26

From the functional point of view, special attention must be given to the “bony valve.” The concept of the bony valve, although infrequently used in the literature, has its one important role in the management of PTND. As previously described in secondary rhinoplasty patients, excessive verticalization of the lateral bony wall after medial osteotomies can result in airway obstruction.²⁷ In PTND, the usual cause of bony valve compromise is compression of the lateral bony wall against the septum (Fig. 3). During the physical examination, a modified Cottle maneuver will reveal the frank level of obstruction when lifting the verticalized upper lateral cartilage with a cotton swab (Fig. 4). In these challenging cases, the usual surgical techniques that address the internal nasal valve (spreader grafts, auto-spreader grafts, suturing) are doomed to fail, unless the osseous lateral wall is mobilized. Osteotomies precede the outward motion with a Boise elevator, and stabilization can be achieved with robust spreader grafts ideally extending underneath the osseous vault and with use of Doyle splints.

Fig. 3.: Posttraumatic medial movement of the bony wall creating verticalization of the upper lateral cartilage and internal nasal valve compromise in three quarters (A) and frontal view (B).

Fig. 4.: Schematic representation of mucosal recruitment before (A) and after (B) division of the upper lateral cartilage bilaterally.

THE SADDLE NOSE

The saddle nose is the aftermath of dorsal septal support deficiency. It is categorized as iatrogenic, traumatic, infectious, related to systemic inflammatory conditions, or related to substance abuse. In contemporary practice, iatrogenic and posttraumatic etiologies constitute the majority of saddle nose cases.^28–30 Despite the common grounds of septal cartilage erosion resulting in degradation of the nasal structure, the etiology of saddle nose will trigger divergent clinical management pathways.

A comprehensive physical examination is the foundation of successful surgical management. Inspection, manual palpation of the external nose, and modified Cottle’s maneuver are indispensable components of the preoperative consultation. In PTND, a saddle nose is often the sequela of an untreated septal hematoma, and preoperative nasal endoscopy is also imperative to ruling out a co-existing septal perforation, which would affect surgical planning.

The role of the skin soft tissue envelope is significant because it can be a restrictive parameter in the reconstruction. After depression of the cartilaginous frame, the skin soft tissue envelope often demonstrates decreased pliability, points of contraction, and diffuse fibrosis. These factors should be identified beforehand to guide decision-making and avoid intraoperative frustrations. A NOSE (Nasal Obstruction Symptom Evaluation) survey questionnaire should be completed by the patient preoperatively, consistent with all functional nasal surgery cases. Classification and stratification of the saddle nose deformity using one of the proposed in the literature classification schemes will also contribute to the surgical decision-making.^31–33 This generally ranges from mild dorsal depression to severe cases with osseocartilaginous collapse.

Cosmetic concerns and shared expectations should be extensively discussed with the patient. The severely complex nature of the deformity and the high possibility for revisions must be openly disclosed.

The classical surgical management of saddle nose is tailored to a three-step approach.³⁰ The cornerstone of the reconstruction is the reconstruction of the traditional L-strut, which allows for correct tip positioning and subsequent dorsal augmentation. In contemporary practice, surgeons enjoy several available options to compensate for the typically cartilage-depleted saddle nose. The historical gold standard is autologous grafting with the septum, auricular cartilage, or rib cartilage serving as potential sources of graft material. Nevertheless, a recent meta-analysis including 28 studies and 1041 patients demonstrated no difference in outcomes between autologous and homologous costal cartilage grafts.³⁴ These included rates of warping, resorption, infection, contour irregularity, and revisions in patients undergoing dorsal augmentation rhinoplasty. Previous studies have also failed to demonstrate considerable difference between autologous and homologous grafts.^35,36 For these reasons, homologous cartilage grafts mainly in the form of irradiated rib are a preferred alternative among plastic surgeons offering low complication rates and unlimited abundance of supply.³⁷

SEPTAL PERFORATION

A septal perforation (Fig. 5) is a challenging complication in PTND. The identification of a septal perforation typically occurs during the preoperative assessment. Upon this finding, the surgeon encounters the unique challenge of combining functional nasal surgical procedures with septal perforation repair. Large-scale, retrospective studies have shown that septal perforation repair may be performed simultaneously with septorhinoplasty without compromising the perforation repair outcome.^38,39 It should be emphasized that this concomitant management requires extensive surgical experience in order to avoid unfavorable outcomes.

Fig. 5.: Schematic representation of the superior and inferior mucosal recruitment in closure of a septal perforation. The interposition graft is seen between the flap. When feasible, the flaps are repaired individually with 5-0 plain gut interrupted. The posterior back cuts typically placed under the inferior turbinates to facilitate inferior mucosal recruitment are omitted for simplicity.

For the functional nasal surgery patient, the most crucial question before surgical planning is whether the septal perforation is partly responsible for the patient’s NAO. Posterior septal perforations are often asymptomatic, and no surgical repair is indicated. As for the typically more symptomatic anterior and smaller perforation of 15-mm maximum diameter, simultaneous repair should be favored as supported by excellent outcomes in the literature.^15,37 In extensive posttraumatic septal perforations, the pericranial flap via an external rhinoplasty or bicoronal approach has been reported as a reliable tool in the surgeon’s armamentarium.^40–43 This extensive procedure will most likely require dedicated time in the operating room, as the surgical maneuvers of a concomitant septorhinoplasty increase operating time and may be technically cumbersome.

ENDONASAL APPROACHES

Endonasal approaches are preferred in the management of PTND, when there are no aesthetic concerns and the deformity is amenable to a conservative surgical approach. These common procedures typically comprise a major part of the otolaryngologist or plastic surgeon’s practice.

Conventional septoplasty in the form of submucosal resection of the deviated parts of the septum is a very common functional nasal surgery procedure in the management of NAO. Traditional teaching implies that minor trauma sustained early in life may result in microfractures of the septal cartilage; healing of these microfractures during development creates unilateral deviation of the quadrangular cartilage away from the side of the injury.⁴⁴ These patients also frequently have a history of midface or nasal bone trauma. When there are no aesthetic needs, a conventional septoplasty is the procedure of choice due to its limited postoperative morbidity and short anesthesia time. Countless septoplasty techniques have been developed since the procedure was introduced in the late 19th century.^45,46 These techniques unanimously involve the removal of deviated cartilage or bone without compromising the integrity of the mucoperichondrial flaps. As with any septoplasty, the excised cartilage should not be disposed but rather crushed and interposed between the mucoperichondrial flaps. This maneuver will decrease the risk of septal perforation and also facilitate revisiting the septum if needed in the future.

INFERIOR TURBINATE REDUCTION

Inferior turbinate reduction can be considered in PTND patients with associated inferior turbinate enlargement. The surgeon should carefully consider the benefits of this intervention as it can increase the risk of postoperative complications, including edema and bleeding. Research studies in inferior turbinate reduction are cumbersome, and myriad surgical techniques are reported without establishment of a single standard of care.^47,48

Inferior turbinate hypertrophy frequently attracts clinical attention when evaluating NAO and formulating a surgical plan. The indication for inferior turbinate reduction during management of PTND follows the diagnosis of inferior turbinate hypertrophy, which is assessed with anterior rhinoscopy with and without topical decongestant.

Surgical evaluation of inferior turbinate reduction classically involves differentiating between removal of bone or soft tissue, or both. The simplest procedure involves repositioning (lateralization) of the inferior turbinate, performed with blunt instrumentation, such as Goldman or Boies nasal elevators. Although fast with low morbidity, this procedure has been criticized for lack of persistent effects with compensatory hypertrophy of the medial mucosa commonly developing 6 months postoperatively.⁴⁹

Submucosal resection of the conchal bone is also well established. This includes a lateral outfracture of the inferior turbinate with submucosal dissection and excision of bone in the inferior half of the turbinate body.⁵⁰ In a recent randomized clinical trial,⁵¹ Elshipli et al compared the outcome of submucous resection versus combined submucous diathermy with outfracture technique in treatment of nasal obstruction caused by inferior turbinate hypertrophy. They concluded that both techniques are effective in relief of NAO, but submucous resection has advantages when assessing long-term follow-up.⁵¹

Other evidence-based inferior turbinate reduction techniques include coblation of the inferior turbinate,⁵² radiofrequency ablation,⁵³ and use of ultrasound.⁵⁴ In a recent systematic review,⁵⁵ Zhang et al reviewed various surgical interventions for inferior turbinate hypertrophy including turbinectomy, submucosal resection, radiofrequency ablation, microdebrider-assisted turbinoplasty, laser, and electrocautery. They reported improvement in NAO in all the above techniques using a visual analog scale for nasal obstruction. Radiofrequency ablation and microdebrider-assisted turbinoplasty were found to have comparable improvements in patient-reported and physiologic nasal airflow outcomes, and while benefits were sustained long-term, the peak benefit for both techniques was achieved within the first year postintervention.

NASAL VALVE INSUFFICIENCY

Nasal valve insufficiency, isolated or in combination with other structural deformities, is commonly present in PTND. The underlying pathogenesis is rooted in principles of physics. In accordance with the Poiseuille Law, constriction of the nasal valve area, as in a newly developed posttraumatic septal deviation, will produce an increase in flow volume and airway resistance. A greater negative inspiratory pressure will develop to compensate for the increased resistance.^56–58

In a preexisting weak sidewall, the new structural factor will result in dynamic collapse and contribute to airway obstruction. Several patients show worsening symptoms years after trauma due to the cumulative effect of age-related loss of cartilage elastic properties and decreasing tone of nasal musculature. When feasible, internal or external nasal valve insufficiency can be addressed with endonasal rhinoplasty approaches. Alar batten grafts can be placed through a limited marginal incision in a precise pocket corresponding to the area of sidewall weakness.^59,60 In accordance with the literature, we frequently favor alar rim grafts as an adjunctive technique in milder deficiency localized mainly to the external nasal valve.^61,62

CONCLUSIONS

PTND represents a sophisticated surgical challenge for the otolaryngologist and plastic surgeon. Endless combinations of deformities can ensue depending on the mechanism of injury, time interval between trauma and consultation, idiosyncratic healing factors, patient’s age, and pretraumatic anatomic variations. Therefore, functional nasal surgery for PTND encompasses a wide spectrum of surgical interventions from traditional septoplasty to complex open septorhinoplasties requiring extensive grafting. An astute conception of the pathophysiology of this deformity is a prerequisite for optimal management of these patients, even in seemingly undemanding cases. A methodical preoperative workup in a standardized manner and systematic surgical planning are indispensable ingredients of a satisfactory outcome.

ACKNOWLEDGMENT

Figures 2, 3, 4 and 5 are courtesy of M. Louka.