Evaluation and Correction of the Crooked Nose

Traumatic Causes

The nasal bones are the most commonly fractured bones in the face, and nasal injury is the most common cause of the crooked nose. True deviation is indicative of a high energy injury and requires greater force than an isolated nasal bone depression or fracture. Usually a significant frontal vector is required for deviation to occur. With trauma, the nasal septum is often fractured or displaced from the maxillary crest. Because the nasal framework becomes more ossified and brittle with age, younger patients tend to have larger fracture segments than older patients, who are more prone to nasal bone comminution. As a general rule, nasal trauma associated with septal fracture requires extensive reconstruction and is unlikely to be adequately treated with closed reduction. The surgeon should also consider psychological repercussions of the incident; such factors may influence the patient's readiness to undergo an elective surgical intervention.

The crooked nose deformity may reflect either the acute outcome of a traumatic episode or a remote injury that has been compounded by years of scarring and soft tissue contracture. The cartilaginous septum is the primary shock absorber of the nose, with lesser contributions from the upper lateral cartilages, alar cartilages, and bony components. Patients with untreated or inadequately reduced nasal fractures may develop a crooked nose gradually, with surface irregularities and asymmetries becoming more conspicuous with the passage of years. Cartilage has a low metabolic rate and frequently heals with scar formation. In cases of remote trauma, the patients may recount a worsening of the deformity with time, often associated with progressive nasal airway obstruction due to disruption of nasal support mechanisms. Repetitive fractures may cause profound structural deficiency, and comminution often will induce aberrant growth.

Many patients with a crooked nose do not remember the inciting traumatic injury. The patient with a severely twisted nose and without history of antecedent trauma is likely to have sustained a childhood injury that was overlooked. Relatively minor cartilage trauma may lead to dramatic deformation over time with chondrocyte growth. The pediatric nose lacks a well-developed bridge and is capable of absorbing substantial energy without showing irregularity until later in life. Children's noses are mostly cartilaginous and are susceptible to injuries that produce progressive deformation over subsequent years of growth. In some cases, septal subluxation or fracture may have occurred during birth. Forceps delivery and breach delivery are risk factors, although the head is also subjected to powerful compressive forces during normal passage through the birth canal. Such early deformities may first become evident during adolescence, as shown in Figure 22-2 .

Iatrogenic Causes

Prior nasal surgery is an important cause of the crooked nose. Asymmetric or incomplete osteotomies often result in deviation and step-off deformities of the upper third of the nose. With green-stick fractures, the bony vault may be subject to residual memory and deviating forces from scarring. Alternatively, if adequate osteotomies are performed but the underlying septal deformity is not addressed, the nasal pyramid will often regress to its original, deviated position. Removal of a dorsal hump in the nose with a straight dorsum and a caudal deviation may unmask an underlying deformity that was not previously visible. Closed reduction of a nasal fracture may result in persistence or creation of a crooked nose if the fracture is not adequately reduced.

Reduction rhinoplasty deserves special consideration due to its potential for creating severe asymmetries that usually become apparent years after surgery. Resection of the nasal osseocartilaginous framework disrupts nasal support mechanisms, often with insidious destabilizing effects. Over the course of years, the contractile forces of scar formation, gravity, and aging conspire to warp and collapse the attenuated nasal scaffold. Such distortions may require major reconstruction years later to address progressive disfigurement and impairment of nasal function. Most rhinoplasty techniques have effects in adjacent zones of the nose during healing. Thus, unexpected deviations often occur from manipulations elsewhere, for example mid vault narrowing and upper lateral cartilage collapse occurring after dorsal hump reduction.

Diseases Involving the Septum and Internal Nose

Several relatively rare pathologic processes may lead to a crooked nose. The surgeon should inquire about symptoms of nasal obstruction and history of epistaxis, allergy, and systemic disease. Autoimmune or immunologically mediated diseases may cause resorption of bony or cartilaginous nasal structures. Granulomatous disease, such as Wegener's granulomatosis or sarcoidosis, and collagen vascular/connective tissue disorders are important diagnostic considerations, particularly in patients with nasal septal perforation or saddling. A history of inhalant abuse, such as cocaine, oxymetazoline, nasal steroids, or NeoSynephrine use, should be considered in cases of mucosal atrophy, ulceration, or nasal perforation. The surgeon should also be alert to infectious etiologies such as tuberculosis, syphilis, and HIV infection. Sinonasal polyposis or neoplastic disease may also induce remodeling and/or splaying of nasal framework.