1. DEFINITION OF EXTERNAL NASAL DEFORMITIES

External nasal deformities refer to visible alterations in the normal shape, contour, alignment, or symmetry of the nose when viewed from any angle (frontal, lateral, basal, oblique).
These deformities may be congenital, traumatic, inflammatory, iatrogenic, developmental, or associated with systemic diseases.
Deformities can affect:
- Bony vault (nasal bones)
- Cartilaginous vault (upper and lower lateral cartilages)
- Septum (key structural foundation that determines shape)
- Soft tissue envelope (skin thickness strongly affects appearance)

The external nose is not merely cosmetic — deformity often reflects underlying structural pathology that directly impacts nasal airflow, hence diagnosis and correction are both functional and aesthetic in ENT.

2. APPLIED ANATOMY FOR UNDERSTANDING DEFORMITIES

External deformities must be mapped to the anatomical region:

2.1 Bony Vault

Formed by paired nasal bones and frontal process of maxilla
Provides upper structural support
Rigid → fractures easily cause deviation or depression

2.2 Upper Lateral Cartilages

Form middle third of dorsum
Create internal nasal valve angle (critical for airflow)
Deformity in this region changes both shape and breathing

2.3 Lower Lateral Cartilages (Alar Cartilages)

Determine tip shape
Deviation causes asymmetry, bulbous tip, or retraction

2.4 Nasal Septum

Foundation of dorsal and caudal support
External deformities almost always reflect septal deviation beneath

2.5 Soft Tissue Envelope

Skin thickness determines severity of visible deformity
Thick skin hides minor defects; thin skin exaggerates them

3. CLASSIFICATION OF EXTERNAL NASAL DEFORMITIES

A. Congenital Deformities

Cleft lip–associated deformities
Congenital asymmetry
Proboscis lateralis
Hemangioma-induced distortion
Genetic cartilage malformations

B. Traumatic Deformities

Post-fracture deviation
Saddle nose (cartilage collapse)
Crooked nose
Depression fractures
Twisted dorsum

C. Developmental Deformities

Septal overgrowth
Unequal cartilage development
Congenital airway stenosis causing compensatory deformity

D. Iatrogenic Deformities

Following rhinoplasty
Post-septoplasty deformities
Over-resection or destabilization
Internal valve collapse

E. Inflammatory/Autoimmune

Sarcoidosis
Wegener’s granulomatosis
Leprosy
Relapsing polychondritis

F. Tumor-related Deformities

Basal cell carcinoma
Squamous cell carcinoma
Dermoid/epidermoid cysts
Lymphoma infiltration

Each category displays specific patterns that help the ENT surgeon distinguish external cosmetic deformity from deeper structural pathology.

4. COMMON TYPES OF EXTERNAL NASAL DEFORMITIES

4.1 Deviated Nose (Crooked Nose)

One of the most common deformities.
Deviation can be:

C-shaped
S-shaped
Tilted
Pyramid shifted

Mechanisms

Trauma → septal + bony deviation
Developmental asymmetry
Septal spur with compensatory deviation
Malunited fracture
Overgrowth of cartilage

Clinical Features

Aesthetic deformity
Nasal obstruction
Snoring/sleep issues
Recurrent sinusitis
Internal valve collapse

Key Point

A deviated nose almost always indicates underlying septal deviation, which must be corrected for lasting results.

4.2 Saddle Nose Deformity

A depression of the nasal dorsum (bridge) due to loss of septal cartilage support.

Etiology

Septal hematoma → cartilage necrosis
Iatrogenic over-resection
Trauma
Autoimmune disease
Cocaine abuse

Anatomical Basis

Loss of L-strut → middle vault collapses.

Appearance

Sunken bridge
Shortened nasal length
Broad nasal base
Upturned tip (pseudo-short nose)

Consequences

Major airway compromise
Valve collapse
Whistling sounds on inspiration

Treatment requires structural grafting, often with costal cartilage.

4.3 Dorsal Hump Deformity

An elevated ridge on the nose caused by:

Prominent nasal bones
Over-projected cartilage
Osteocartilaginous deformity

Causes

Genetic (most common)
Post-trauma (bony callus formation)
Developmental overgrowth

Impact

Aesthetic concern
May cause internal valve narrowing if asymmetrical

4.4 Open Roof Deformity

Occurs when the dorsal bones separate due to injury or surgery.

Mechanism

Faulty closed reduction
Previous rhinoplasty
Comminuted fractures

Appearance

Wide flat dorsum
Visible bony edges
“Widened” appearance on front view

Requires osteotomies for correction.

4.5 Inverted V Deformity

Visible concavity at the junction between nasal bones and upper lateral cartilages.

Etiology

Collapse of upper lateral cartilages
Over-aggressive dorsal reduction
Trauma → separation of ULC from septum

Key Functional Implication

Internal nasal valve obstruction → major breathing difficulty.

4.6 Tip Deformities

A. Bulbous Tip

Wide lower lateral cartilages
Thick skin
Poor tip definition

B. Boxy Tip

Widely spaced LLCs
Horizontal tip orientation

C. Droopy Tip

Weak support
Overdominant septal angle

D. Asymmetric Tip

Trauma
Developmental cartilage imbalance

Tip deformity management requires precise cartilage manipulation.

4.7 Alar Deformities

Types

Alar retraction
Alar collapse
Wide alar base
Notching of ala
Asymmetry

Causes

Trauma
Congenital weakness
Over-resection in rhinoplasty
Scarring

Alar collapse compromises external valve function → inspiratory obstruction.

4.8 Columellar Deformities

Types

Hanging columella
Retraction
Columellar deviation

Causes

Septal extension graft issues
Maxillary deficiency
Previous surgery
Trauma

Columella plays a central role in tip support.

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

5. PATHOGENESIS OF EXTERNAL NASAL DEFORMITIES

5.1 Trauma-Related Mechanisms

Shearing of mucoperichondrium → compromised blood supply
Septal hematoma → cartilage necrosis → collapse
Bony fractures healing in malaligned position
Comminution → asymmetrical scar contracture
Displacement of upper lateral cartilages

5.2 Developmental & Congenital Mechanisms

Differential growth of cartilage and bone
Midface hypoplasia
Cleft lip–associated rotated cartilage
Intrinsic weakness of cartilage framework
Abnormal fusion of nasal processes

5.3 Iatrogenic Causes

Over-resection of dorsal septum
Inadequate preservation of L-strut
Excessive trimming of lower lateral cartilages
Incomplete osteotomies
Graft warping
Compensatory scarring causing secondary deformity

5.4 Inflammatory / Autoimmune Pathogenesis

Autoimmune diseases cause:

Chronic chondritis
Cartilage breakdown
Inflammatory fibrosis
Collapse of dorsum and alae

Examples:

Granulomatosis with polyangiitis
Relapsing polychondritis
Leprosy

5.5 Tumor-Related Distortion

Benign or malignant tumors can lead to:

Local destruction
Asymmetry
Mass effect pushing nasal structures
Post-excision contour defects

6. CLINICAL FEATURES OF EXTERNAL NASAL DEFORMITIES

External nasal deformities affect appearance and function. ENT assessment must link the visible abnormality with deeper anatomical disruption.

6.1 Aesthetic Features (Seen on Inspection)

Asymmetry in dorsal line
Deviation of nasal pyramid
Irregular contour or step deformity
Depression (saddle nose) or elevation (callus/hump)
Tip abnormalities
- Drooping
- Bulbous
- Asymmetric
- Retracted
Alar abnormalities
- Collapse
- Widening
- Retraction
Nasal valve collapse visible during forced inspiration
Scarring, tethering, or skin changes
Dorsal widening (open roof deformity)
Midvault narrowing (inverted V deformity)
Enlarged turbinates visible through nostrils due to compensatory hypertrophy

6.2 Functional Features (Internal Consequences)

External deformities almost always mirror deeper internal abnormalities.

A. Nasal Obstruction

Due to septal deviation
Valve collapse
Alar insufficiency
Turbinate hypertrophy
Narrowed internal nasal valve (angle <10°)

B. Snoring & Sleep Disturbances

Poor airflow → mouth breathing → snoring
Can worsen obstructive sleep apnea

C. Recurrent Rhinosinusitis

Deviations and collapse disturb sinus drainage pathways

D. Epistaxis

Turbulent airflow causes mucosal dryness
Deviated spurs traumatize mucosa

E. Headache / Facial Pain

Contact point headache from septal spur

F. Reduced Smell

Obstruction of olfactory airflow

6.3 Psychological & Social Effects

Though ENT exams rarely emphasize this, clinical practice demands awareness.
Patients often report:

Low self-esteem
Social avoidance
Persistence of “nasal insecurity” post-trauma
Anxiety around facial symmetry

This matters because expectation management is key before surgical correction.

7. EXAMINATION OF EXTERNAL NASAL DEFORMITIES

An ENT surgeon examines the nose from five standard angles:

Frontal
Lateral
Three-quarter (oblique)
Basal
Superior

7.1 General Inspection Checklist

Nasal dorsum alignment
Tip projection & rotation
Symmetry of upper, middle, and lower thirds
Skin thickness
Scars (previous trauma/surgery)
Nostril symmetry
Alar position
Valve collapse on inspiration (Cottle test)
Dorsal contour (hump, depression, irregularity)

7.2 Palpation

Mobility of nasal bones
Detection of bony steps
Tenderness
Bone crepitus (post-trauma)
Septal deviation felt anteriorly
Integrity of upper lateral cartilages
Tip support test (gentle pressure to see recoil)

7.3 Internal Nasal Examination

Performed using:

Thudichum speculum
Headlight
Endoscope (0°/30°)

Look for:

Septal deviation
Spurs
Valve collapse
Turbinate hypertrophy
Synechiae
Polyps
Mucosal edema
Post-traumatic tears
Saddle nose correlation with absent septal cartilage

7.4 Functional Assessment

Important tests:

A. Cottle Maneuver

Lateral traction on cheek → improvement = valve collapse.

B. Modified Cottle Test

Evaluate exact site of collapse by sequential lateralization.

C. Nasal Endoscopy

Internal valve angle
Septal deviation pattern
Turbinate size
Mucosal pathology
Synechiae

D. Peak Nasal Inspiratory Flow (PNIF)

Objective airflow measurement.

E. Acoustic Rhinometry

Determines cross-sectional area of nasal cavity.

8. INVESTIGATIONS FOR EXTERNAL NASAL DEFORMITIES

8.1 No investigation is needed for routine deformities, but required when:

Trauma is recent
Functional obstruction exists
Preoperative planning is required
Associated sinus disease is suspected

8.2 Imaging Modalities

A. X-ray Nasal Bones (Obsolete in many centers)

Shows fracture lines
Poor soft tissue visualization
Used only where CT unavailable

B. CT Scan (Gold Standard in Trauma & Complex Deformity)

CT axial + coronal + sagittal views visualize:

Bony fractures
Septal fractures
Dorsal irregularities
Osteotomies planning
Sinus pathology
Cribriform plate trauma

3D reconstruction invaluable for:

Preoperative planning
Asymmetry assessment
Medico-legal documentation

8.3 Nasal Endoscopy

Internal valve collapse
Septal deviation/spur
Turbinate hypertrophy
Synechiae
Inform airway–external shape correlation

8.4 Photographic Documentation

Standardized photos needed in ENT:

Frontal view
Right lateral
Left lateral
Basal
Oblique
Smiling (dynamic deformity)

These assist in:

Preoperative planning
Communication with patient
Medicolegal clarity

9. DIFFERENTIAL DIAGNOSIS FOR EXTERNAL NASAL DEFORMITIES

ENT surgeons must distinguish true deformity from pseudo-deformity or soft-tissue asymmetry.

9.1 Deviated Nasal Pyramid DDs

Deviated septum without external deviation
Facial asymmetry (zygomatic/midface)
Unilateral turbinate hypertrophy mimicking deviation

9.2 Dorsal Depression DDs

Saddle nose (loss of support)
Post-rhinoplasty over-resection
Relapsing polychondritis
Wegener’s granulomatosis
Cocaine-induced destruction
Leprosy

9.3 Dorsal Hump DDs

Osteocartilaginous hump
Bony callus after fracture
Dorsal tension nose (overprojected septum)

9.4 Tip Asymmetry DDs

Septal caudal deviation
Weak LLC on one side
Congenital cartilage deformity
Cleft lip–associated twist

9.5 Alar Collapse DDs

Facial nerve palsy
Congenital weakness
Prior surgery over-resection
Trauma

9.6 Columellar Abnormalities DDs

Maxillary hypoplasia (pseudo-hanging columella)
Overlong septal extension graft
Short membranous septum

10. MANAGEMENT OF EXTERNAL NASAL DEFORMITIES

Management is divided into:

Non-surgical (limited value)
Surgical (definitive correction)

10.1 Non-Surgical

A. Medical Treatment

Only beneficial if deformity has a mucosal origin:

Turbinate hypertrophy → topical steroids
Rhinitis improving internal airflow
Edema reduction post-trauma

B. Nasal Strips & Dilators

Temporary relief of valve collapse.

C. Post-trauma Immediate Care

Cold compresses
Avoid pressure
Swelling protection

But non-surgical management cannot correct structural deformity.

10.2 Surgical Management — ENT Standard Framework

Surgical correction varies depending on deformity and is grouped under:

A. Closed Reduction**

Used ONLY for acute traumatic deformities (<10 days).

Repositions displaced nasal bones
Limited access

B. Open Reduction / Rhinoplasty**

Standard for all long-standing deformities.

Includes:

Septoplasty
Osteotomies
Cartilage grafting
Dorsal reshaping
Tip reconstruction
Valve correction

C. Septorhinoplasty (Functional + Aesthetic Correction)

Essential when deformity is combined with obstruction.

D. Reconstructive Rhinoplasty

Required for:

Saddle nose
Cleft-lip nose
Post-surgical collapse
Severe trauma

Often uses:

Costal cartilage grafts
Spreader grafts
Alar batten grafts
Columellar struts
Onlay grafts

11. SURGICAL CORRECTION OF SPECIFIC NASAL DEFORMITIES

External nasal deformity correction requires ENT surgeons to restore structure, symmetry, and airway function. Each deformity demands a tailored surgical strategy.

11.1 Correction of Deviated Nose (Crooked Nose)

A. Principles

Deviation originates from both bony and cartilaginous vaults.
Septum is the foundation — external correction fails if septal deformity remains.
Correction requires a three-step approach:
1. Straighten septum
2. Realign nasal bones
3. Reconstruct middle vault

B. Surgical Technique

1. Septoplasty

Remove deviated portions
Preserve a strong L-strut
Fix caudal septum in midline (crucial for tip symmetry)

2. Osteotomies

Performed to realign nasal bones:

Medial osteotomy → frees nasal bones
Lateral osteotomy → repositions pyramid
Intermediate osteotomy → corrects midvault asymmetry

3. Spreader Graft Placement

Restores:

Internal nasal valve angle
Symmetry of dorsum
Stability of middle vault

4. Tip Correction

Correct LLC asymmetry
Tip sutures (interdomal, transdomal, lateral crural steal)

C. Postoperative Care

External splint for 1–2 weeks
Internal splints if septal work done
Avoid trauma for 6 weeks

11.2 Correction of Saddle Nose Deformity

A. Principles

Saddle nose results from loss of dorsal septal support, requiring reconstruction of a new structural framework, not just surface correction.

B. Graft Materials

1. Costal Cartilage (Preferred)

Strong
Abundant
Best for severe collapse

2. Septal Cartilage (Mild Deformity)

Limited quantity

3. Conchal Cartilage (Tip & Ala)

Curved shape suitable for alar reconstruction

C. Surgical Steps

Harvest graft (usually rib cartilage)
Carve dorsal onlay graft
Reconstruct L-strut
Secure graft to septum
Add spreader grafts for middle vault
Tip support reinforced with columellar strut
Adjust alae for symmetry

D. Key Points

Prevent graft warping by balanced carving
Rib graft must be fixed to avoid rotation
Overcorrection slightly, anticipating resorption

11.3 Correction of Dorsal Hump Deformity

A. Hump Removal Technique

Includes both bone and cartilage.

Steps:

Elevate soft tissue envelope
Separate ULCs from septum
Remove hump precisely
Reconstruct middle vault using spreader grafts to prevent inverted V
Osteotomies to close open roof

B. Avoiding Complications

Preserve enough septum to maintain dorsal stability
Smooth edges to prevent postoperative irregularities

11.4 Correction of Open Roof Deformity

Caused by:

Hump reduction
Trauma
Incomplete healing

Surgical Correction

Bilateral osteotomies
Medialization of nasal bones
Placement of spreader grafts if required
Onlay grafts for fine contouring

11.5 Correction of Inverted V Deformity

A. Cause

Separation/collapse of ULC from septum.

B. Correction

Restore ULC-septum attachment
Insert spreader grafts to re-expand middle vault
Recreate internal nasal valve angle

Functional Benefit

Eliminates major airflow resistance.

11.6 Tip Deformities — Surgical Management

A. Bulbous Tip

Cephalic trimming of LLC
Tip-suturing techniques
Shield graft if needed

B. Droopy Tip

Increase rotation by:
- Septal extension graft
- Lateral crural steal
- Columellar strut placement

C. Asymmetric Tip

Reposition distorted LLC
Cartilage grafts to balance tip projection
Sometimes caudal septal correction required

D. Boxy Tip

Reduce horizontal width with interdomal sutures

11.7 Alar Deformities — Surgical Management

A. Alar Retraction

Composite grafts (skin + cartilage)
Lateral crural repositioning

B. Alar Collapse

Alar batten graft → restores external valve strength

C. Wide Alar Base

Alar base reduction (Weir excision)

D. Alar Asymmetry

Cartilage repositioning
Soft tissue adjustments

11.8 Columellar Deformities — Surgical Management

A. Hanging Columella

Shorten caudal septum
Trim excess membranous septum
Adjust tip projection

B. Retracted Columella

Columellar strut
Tip grafts

C. Deviated Columella

Correct caudal septum
Symmetrical suturing

12. POSTOPERATIVE CARE & FOLLOW-UP

12.1 Immediate Postoperative Instructions

External splint maintained 7–10 days
Ice packs for swelling
Sleep with head elevated
Avoid blowing nose 2 weeks
Avoid glasses resting on nasal dorsum

12.2 Long-Term Care

Edema may persist 3–12 months
Gentle nasal saline irrigation
Avoid contact sports 6 weeks
Scar management for open rhinoplasty incision

13. COMPLICATIONS OF SURGICAL CORRECTION

A. Early Complications

Hematoma
Infection
Bleeding
Mucosal tears
Septal perforation
Tip numbness

B. Late Complications

Residual deformity
Recurrence of deviation
Graft resorption
Graft warping
Valve collapse
Persistent asymmetry
Dorsal irregularity
Septal perforation (rare but serious)

14. PROGNOSIS

Depends on:

Severity of deformity
Underlying septal integrity
Quality of graft material
Surgical technique
Skin thickness (thin skin exposes contour irregularities)

Developmental deformities have the best long-term outcomes.
Traumatic & iatrogenic deformities are more challenging.

15. EXAM & VIVA POINTS (HIGH-YIELD)

“External deformity almost always reflects internal septal pathology.”
“Septal hematoma is the most important red-flag in nasal trauma.”
“L-strut preservation is mandatory for dorsal and tip support.”
“Spreader grafts correct both function (valve) and form (dorsal line).”
Open roof deformity is corrected by osteotomies.
Saddle nose → treat with structural grafting, not fillers.
Inverted V deformity → collapse of upper lateral cartilages.

16. MCQs (20 HIGH-YIELD QUESTIONS)

1. External deformities most commonly arise from pathology in:

A. Lower lateral cartilages
B. Upper lateral cartilages
C. Septum
D. Skin envelope
Correct Answer: C

2. Saddle nose is due to:

A. Hypertrophy of ULC
B. Overgrowth of LLC
C. Loss of septal support
D. Thick skin
Correct Answer: C

3. Inverted V deformity results from collapse of:

A. Lower lateral cartilages
B. Upper lateral cartilages
C. Nasal bones
D. Tip graft
Correct Answer: B

4. Best graft for severe saddle nose:

A. Septal
B. Conchal
C. Costal
D. Fascia
Correct Answer: C

5. Internal nasal valve angle is normally:

A. 5–10°
B. 10–15°
C. 15–25°
D. 25–35°
Correct Answer: C (approx 15°)

6. Cottle test evaluates:

A. Dorsum symmetry
B. Tip projection
C. Nasal valve collapse
D. Septal perforation
Correct Answer: C

7. Open roof deformity corrected by:

A. Tip suturing
B. Osteotomies
C. Conchal graft
D. Alar base reduction
Correct Answer: B

8. Bulbous tip is due to:

A. Thin skin
B. Thick LLC
C. Spreader collapse
D. Valve stenosis
Correct Answer: B

9. In alar collapse, the best graft is:

A. Batten graft
B. Spreader graft
C. Onlay graft
D. Columellar strut
Correct Answer: A

10. Dorsal hump consists of:

A. Bone only
B. Cartilage only
C. Bone + cartilage
D. Soft tissue
Correct Answer: C

11. Best investigation for deformity with sinus pathology:

A. X-ray
B. CT
C. MRI
D. Ultrasound
Correct Answer: B

12. Septal cause of external deviation is:

A. Caudal septal deviation
B. Turbinate hypertrophy
C. Synechiae
D. Mucosal edema
Correct Answer: A

13. Main support of nasal dorsum:

A. LLC
B. Skin
C. Septum
D. Turbinates
Correct Answer: C

14. Hanging columella caused by:

A. Short septum
B. Long caudal septum
C. Thick skin
D. Weak LLC
Correct Answer: B

15. Most common soft-tissue pseudo-deformity:

A. Turbinate hypertrophy
B. Alar collapse
C. Bony deviation
D. Polyp
Correct Answer: A

16. Post-trauma widened dorsum suggests:

A. Saddle nose
B. Open roof deformity
C. Valve collapse
D. Tip ptosis
Correct Answer: B

17. Functional consequence of inverted V deformity:

A. Tip droop
B. Valve obstruction
C. Nostril asymmetry
D. Columellar retraction
Correct Answer: B

18. Primary goal in crooked nose correction:

A. Tip refinement
B. Skin thinning
C. Septal straightening
D. Dorsal augmentation
Correct Answer: C

19. Alar base reduction corrects:

A. Saddle nose
B. Wide nostrils
C. Tip droop
D. Valve collapse
Correct Answer: B

20. Most reliable long-term graft:

A. Conchal
B. Fascia
C. Rib cartilage
D. Alloplastic implant
Correct Answer: C