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4.2 Examination ofNose andParanasal Sinuses
a b
Fig. 4.18 Cottle’s test/Cottle’s manoeuvre
189
(HSVM) and transmission electron microscopy (TEM).
• Clinical tests for olfactory function/smell:
– SniffIn-sticks smell test (SS): The 12
odorants in the SniffIn-sticks test are
orange, leather, cinnamon, peppermint,
banana, lemon, liquorice, coffee, cloves,
pineapple, rose and sh. The sticks were
placed 1 cm from one nostril, and the
patient was asked to inhale with the other
nostril closed, and the test was repeated in
the other nostril. The subjects were asked
to identify the correct smell from a set of
four choices for each item from an answer
card. The rst response was taken and
scored 1 for correct and 0 for wrong answer.
– Indian smell identication test: The
essence of ten commonly used items was
used as odorants. The odorants were chosen
to represent the familiarity in day-to- day
life. The essence of cardamom, kewra, khus,
lemon, mango, orange, pineapple, rose,
thinner and vanilla in 20mL air-tight bottles
commercially available was used. Cotton
buds dipped in the essence were used as test
material, which were placed 1cm in front of
the nostril with the other closed and repeated
in the other. The subject was asked to sniff
and identify the smell from the answer card
containing four choices for each odorant.
The rst response was taken and scored 1
for correct and 0 for wrong response.
– Butanol threshold test: The butanol thresh-
old test involves a forced-choice test using
an aqueous concentration of butyl alcohol in
one sniff bottle and water in the other. The
patient is asked to identify the bottle containing the odorant, with each nostril tested
separately. After each incorrect response,
the concentration of butanol is increased by
a factor of 3 until the patient either achieves
ve correct responses or fails to correctly
identify the bottle with 4% butanol. The
detection threshold is recorded as the concentration at which the patient correctly
identies the butanol on ve consecutive trials. The scoring relates the patient’s threshold to a normal subject population.
Differential diagnosis of nasal obstruction (Table 4.25)
Table 4.25 Differential diagnosis of nasal obstruction
U/L Nasal obstruction B/L Nasal obstruction
U/L turbinate hypertrophy, U/L
chronic rhinosinusitis, DNS,
DNS with paradoxical HIT,
antrochoanal polyp, inverted
papilloma, benign or malignant
tumours,
meningoencephaloceles, JNA,
sphenochoanal polyp, U/L
synechia
Adenoid hypertrophy,
ethmoidal polyp, B/L
HIT, DNS with
compensatory HIT, B/L
concha bullosa, B/L
sinusitis, septal
haematoma, septal
abscess, B/L synechia
190
4 History andExamination ofNose andPara Nasal Sinuses
4.2.1.3 Aesthetic Examination ofNose
Ideally, the beautiful nose is approximately 1/5 of
the width of the face. In general, the width of the
entire nose (nostril width) should not be wider
than the distance between the eyes. In other
words, the nostrils should t between imaginary
lines drawn from the inside of each eye. The width
of the bridge of the nose (‘dorsum’), in turn,
should be about 80% of the width of the nostrils.
A beautiful nose is dened as a nose with
a straight or slightly concave dorsum, a
moderate nasofrontal angle at the radix, a
mild width bony pyramid, good tip projection/rotation, parallel aesthetic dorsal lines
and length proportional to facial height.
1. Anatomical landmarks
(a) Anatomical landmarks of frontal view
of nose (Fig. 4.19):
• Trichion point—It is the point where
the normal hairline and middle line of
the forehead intersect.
• Glabella point—The glabella, in
humans, is the area of skin between
the eyebrows and above the nose. The
term also refers to the underlying bone
that is slightly depressed and joins the
two brow ridges. It is a cephalometric
landmark that is just superior to the
nasion.
• Radix—The radix is a depression at
the root of the nose, which denes the
nasal root and the origin of the nose
from the point of the glabella.
Inferiorly, it extends from the nasion
to the level of a horizontal line passed
through the lateral canthi superiorly
from the nasion for an equivalent
distance.
• Nasion—The nasion (/ˈneɪziɒn/) is the
most anterior point of the frontonasal
suture that joins the nasal process of
the frontal bone and nasal bones. It
marks the midpoint at the intersection
of the frontonasal suture with the internasal suture joining the nasal bones.
• Rhinion—It is the anterior tip at the
end of the suture of the nasal bones.
• Nasal tip-dening points—They are
very anterior projections of the tip at
the apex of the tip lobule and are
formed by the junction of the medial
and lateral crura of each lower lateral
cartilage. The tip-dening point is
what provides highlights on the frontal view, created by the dome of the
lower lateral cartilage. These are the
most projecting points at intermediate
crus.
• Sellion—It is an osseocartilaginous
junction of nasal dorsum.
• Nasal bone—An elongated rectangular bone that forms the bridge of the
nose. They are two in number, attached
to each other in midline, laterally to
maxilla, superiorly to frontal bone and
inferiorly to upper lateral cartilage.
• Supratip—This is the area just cephalad to tip.
• Nasal tip—The junction of the inferior margin of the nasal ridge/nasal
dorsum and the columella.
• Subnasale—A point on the living
body where the columella and the
upper lip meet in the midsagittal plane.
• Stomion—A soft tissue cephalometric
landmark dening the contact point of
the upper and lower lips in the midsagittal line when the mouth is closed.
• Menton—It is the most inferior point
of chin.
• Pogonion—It is the most anterior
midline soft tissue point of chin.
• Gnathion—Point of intersection
between line tangent to submental
region
• Frankfurt plane—It is dened by a
line from the most superior part of
EAC to the most inferior point of the
infraorbital rim.
ab
cd
4.2 Examination ofNose andParanasal Sinuses
Tr ichon
191
Radix
Rhinion
Subnasion
Menton
Glabella
Nasion
Zygoma
point
Stomium
B
A
Fig. 4.19 Anatomical landmarks on frontal view of nose (a) Anatomical landmarks, (b) Dorsal aesthetic lines, (c)
Horizontal third of nose, (d) Interpupillary distance (B) and intercanthal distance (A)
• Dorsal aesthetic lines—They are
dened as lines originating on the
supraorbital ridges, traversing medially along the glabellar area, converging at the medial canthal ligaments,
diverging at the keystone area (junction of bony with upper lateral cartilage) and terminating at the nasal tip.
They can be straight, symmetrical or
asymmetrical, well or ill dened, narrow or wide.
(b) Anatomical landmarks on oblique view
(Fig. 4.20): If it adds anything or conrms
the other ndings.
(c) Anatomical landmarks on lateral view
(Fig. 4.21):
• Anterior facial plane—A line from
the glabella to the pogonion creates
the anterior facial plane.
• Nasal tip angle—It is an angle formed
between the line from the base of the
nose to the tip and the line along the
192
Subnasal
4 History andExamination ofNose andPara Nasal Sinuses
Tr ichon
Glabella
Radix
Nasion
Supra tip
Alar lobule
Soft triangle
Nasal sill
Nasolabial
fold
Fig. 4.20 Anatomical landmarks on oblique view
Glabella
Nasion
Rhinion
Supra tip
Tip
e
Stomion
Pogonion
Menton
Naso frontal
angle
Nasolabial
angle
1
⁄
3
1
⁄
3
1
⁄
3
T
G
S
P
Anterior
facial plane
A
N
C
SN
B
Fig. 4.21 Anatomical landmarks on lateral view like planes, angles and planes and nasofrontal, nasomental, nasofacial
angle, nasofrontal angle and nasolabial angle in male and female
4.2 Examination ofNose andParanasal Sinuses
193
Fig. 4.21 (continued)
120-130˚
95-105˚
Nasofrontal angle
Naso-labial angle
Nasofrontal angle
Naso
frontal angle
Nasomental
angle
Nasomental angle
115-120˚
90-95˚
Naso
frontal angle
Nasomental
angle
194
ab
cd
4 History andExamination ofNose andPara Nasal Sinuses
Naso-facial angle- Male Naso-facial angle- Female
N
N
Pq
Pq
Nasolabial angle in Male
Fig. 4.21 (continued)
columella. The nasal tip angle
determines whether a nose is perceived
as upturned or down-turned and can
lead to the appearance of either a
celestial/snub nose or a hooked nasal
appearance (Roman, hawk). The normal range is 65°–81°.
• Nasofrontal angle—The angle
formed between the line from the
nasion to the glabella and the line from
the nasion to the nasal tip is known as
the nasofrontal angle. This varies from
115° to 130°.
• Nasomental angle—It lies between
the line along the dorsum to the nasion
and a line drawn from the nasal tip up
to the pogonion. Normal 120°–132°.
• Nasofacial angle—It is formed
between the anterior facial plane and
the line tangent to the dorsum of the
nose. It is dened by the angle formed
by the transection of the glabella pogonion line with nasion-to-tip line.
Normal 30°–40°.
• Nasovertical angle—The angle
formed between the anterior facial
plane and nasal dorsum. It should be
around 120°.
• Columellar lobular angle—This
angle is formed at the junction of the
columella and the infratip lobule and
indicates the junction of the middle
and medial crura. It is also known as
the angle of rotation. It is the angle
between the columella breakpoint, and
its average range is 50°–60°.
• Legan facial convexity angle—The
angle formed by the glabella-to-
Nasolabial angle in Female
4.2 Examination ofNose andParanasal Sinuses
195
subnasale line intersecting with the
subnasale- to-pogonion line. Normal
8°–16°.
• Columellar labial angle—It is
dened as the angle formed by the
columella and upper lip.
• Nasolabial angle—The nasolabial
angle is an angle that is formed
between the columella and the upper
lip. A range from 95° to 115° is considered desirable in women, whilst
90°–95° is preferred in men. It is an
indirect measure of tip rotation.
However, these angles are approximations, and narrower angles are appropriate in taller patients. The nasolabial
angle can be obtuse, acute and
normal.
• Nasomental line—The nasomental
line connects the nasal tip to the lips
and then the chin. The chin should
deviate no more than 4mm on either
side of the nasomental line to be considered attractive.
• Ala facial groove—The alar crease or
alar facial groove is the junction between
the nose and cheek. A cephalically positioned alar facial junction will lead to a
snarled appearance of the nose, while a
caudally positioned alar facial junction
can lead to alar hooding.
(d) Anatomical landmarks on nasal tip:
• Supratip break—A nose in which tip
projection slightly exceeds the prole
line of the nose.
• Right dome—It is formed by the
intermediate crus of the right alar
cartilage.
• Left dome—It is formed by the intermediate crus of the left alar cartilage.
• Columella lobular junction (colu-
mellar break point)—It marks the
transition from columella to tip lobule.
• Tip-dening point—Dome or tip-
dening point is the most projected
portion of the transition zone between
the medial and lateral crus. The ideal
axis of dome-dening point is 45°
from the midline.
(e) Anatomical landmarks on basal view
(Fig. 4.22):
• Nose width—It is measured from one
ala to the other.
• Inter-alar angle—It is formed near
the nose tip by the two tangents touching the alar on either side. It is used to
classify the nose shape into different
morphological types.
• Interaxial angle—It is formed at the
apex where two nostrils meet. It is
closely related to the nostril incline.
• Subnasion/subnasale—The subnasale is the midpoint of the angle at the
columella base where the lower border
of the nasal septum and the surface of
the upper lip meet.
• Subalar—The labial insertion of ala is
termed as subalar.
• Infratip lobule—The infratip lobule
is the area of the nose bounded by the
tip-dening points superiorly and the
columella caudally.
• Columella—This is the most anteroinferior portion of the nasal septum
and forms the central eshy portion
between the two nostrils.
• Domal angle—It is an angle between
the medial and lateral crus at the dome
on each side.
• Divergence angle—The domes of the
medial crura diverge from each other
at 50–60 that is called divergence
angle. A narrow divergence angle
causes the tip-dening points to be too
close together and gives a pinched or
‘uni tip’ appearance, and a wide angle
causes a boxy tip.
Anatomical landmarks of the external nose (Figs. 4.19, 4.20, 4.21 and
4.22)
196
Anatomical landmarks on tip of nose
Anat
4 History andExamination ofNose andPara Nasal Sinuses
Angle of divergence
Inter alar breadth
omical landmarks on basal view –
Angle of divergence
Inter Alar angle
Fig. 4.22 Anatomical landmarks on the basal view of the nose
Anatomical landmarks on frontal
view of nose
Anatomical landmarks on oblique
view
Anatomical landmarks and angles
on lateral view (Fig. 4.21)Anatomical landmarks on tip of
nose
Anatomical landmarks on basal
view
2. Aesthetic analysis of nose (nasal analysis or
rhinoplasty analysis): The rhinoplasty analy-
sis of the nose is done by studying images
taken on six standard rhinoplasty views (frontal, right/left oblique, right/left lateral and
basal). Frontal, oblique and lateral views are
Dome angle
Inter axial
angle
Sbal int.
Sbal ext.
Nostril
axis angle
taken with the patient in the Frankfort horizontal position. The analysis begins by examining all four views, making an assessment of
the overall stature of the patient, facial skin
quality and asymmetry of the face. The face is
divided into a horizontal third and a vertical
fth to obtain knowledge about any incongruent area of the face that plays a key role in
nasal appearance. The visual examination and
nger palpation of the nose are also equally
important for nasal evaluation.
(a) Frontal view (front of the nose)—On the
frontal view, the face itself is described in
terms of horizontal thirds and vertical
fths. The nose forms the central fth on
the vertical fth and the middle 1/3 on the
height
ab
cd
4.2 Examination ofNose andParanasal Sinuses
Fig. 4.23 Frontal view,
(a) Interpupillary and
intercanthal distance, (b)
Shows nasal root width
and intercanthal
distance, (c) Shows
nasal height, nasal
breadth and nasal length,
(d) Curvature of nose (n
nasion, sn subnasale)
197
abb
B
A
a
N
Sn
S
a-a- Intercanthal distance
b-b- Nasal root width
Nasal
horizontal third. The nose is divided into
three. The upper third, formed by nasal
bones, upper lateral cartilages and dorsal
septum, forms the middle third and the
lower lateral cartilage and tip form the
lower third. While doing an examination
of the frontal view, the surgeon rst notes
any deviation of the dorsum from the
midline, nasal width and nasal tip
(Fig.4.23).
• Dorsum of the nose (bridge of the
nose)—The nasal dorsum is also
called the ‘bridge’ of the nose; it spans
between the root and tip of the nose.
There are variations of an attractive
N
Nasal
length
SN
Nasal
breadth
dorsum. A straight dorsum between
the radix (depression at the root of the
nose) and the tip with no supratip
break, or a straight dorsum reduced to
a level approximately 2mm below the
tip, creating a retrousse with a supratip
break (preferred by Caucasian
females), are both considered attractive dorsum. The dorsum is examined
for any deviation, shape, width or
curvature.
– Position of the dorsum of nose
No deviation or midline—The
normal dorsum should be
straight and in midline.
198
4 History andExamination ofNose andPara Nasal Sinuses
Deviated dorsum—Any deviation from the midline to one side
or other results in asymmetry
and causes cosmetic deformity
of the nose. The bony and cartilaginous portions of the dorsum
are examined separately because
they both can deviate to the same
side, one may deviate while the
other is midline, or both may
deviate in opposite directions. In
general, when dorsal deviation
is present, the opposite side of
the dorsum is longer than the
side to which the dorsum is
deviated. The deviated dorsum
is examined on various
parameters.
Type of deviation
If the whole of the dorsum of the
nose is away from the midline.
This type of dorsum is present in
the deviated nose.
If the dorsum of the nose does
not follow a straight, vertical
line down the centre of the face
but deviates to either sides or
part is deviated from one side or
another in the centre or deviated
to the other side. This is known
as crooked dorsum present in a
crooked nose.
Degree of deviation—A line
starting from the midline glabella to the mention helps to
assess the degree of deviation. It
may be grade 0 to grade 3.
– Width of the dorsum of nose/dorsal
width—It describes the horizontal
dimension of the dorsum and is
dened by two line runs on the lateral side of the nose (dorsal aesthetic lines). The bony dorsum
includes the frontal processes of the
maxilla, nasal portions of the frontal bones, and the nasal bones,
whereas the cartilaginous portion is
composed of the upper lateral cartilage. It should be about 80% of the
width of the nostrils. The width of
the dorsum is inuenced by the
width of the nasal bones. They can
coincide (e.g. both too wide, too
narrow or normal) or differ (e.g.
wide nasal bones, normal or narrow
upper lateral cartilage or wide
upper lateral cartilage but normal or
narrow bony dorsum).
– Curvature of dorsum—On frontal
view, the dorsum should be straight,
but it may be either C shaped or S
shaped. The variance from straight
can be primarily bony or primarily
cartilaginous, or it can involve both
parts of the dorsum nearly equally.
• Nasal root width—The ideal width of
the nasal bony vault depends on several factors such as facial width, nasal
length, tip sharpness and skin thickness. However, it is still usually
acceptable when the width is twothirds of the alar base width or twothirds of the intercanthal distance
(Fig.4.23b).
• Vault of nose
Bony/upper vault—The nasal bones
are paired structures that attach
superiorly to the frontal bone and laterally to the nasal process of the maxillary bones. These structures together
form the bony nasal vault.
Mid-vault (upper cartilaginous
vault)—The middle nasal vault is a sen-
sitive region of the nose from both an
aesthetic and a functional perspective.
The middle vault is a transition zone
between the nasal tip and nasal bones
and plays an important role in prole, tip
projection, tip rotation and tip support.
Lower vault—It is a cartilaginous
structure composed of paired lower
lateral cartilage. Lower vault inuence
tip projection, rotation and denition.
• Nasal Length (nasal bridge length)—
The nasal bridge length is the distance
between the soft tissue of the nasion
and pronasale. It usually measures
between 45 and 50mm. It is equal to