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4.2 Examination ofNose andParanasal Sinuses
Fig. 4.24 Lateral view,
(a) Showing nasal
bridge length/nasal
length (n–prn), Nasal
height (n–sn), Nasal tip
protrusion (sn–prn), (b)
Shows the relationship
between midfacial
height and nasal
projection and nasal tip
angle, (c) Shows radix
projection, (d)
Alar-columellar
relationship
Nose height
N
PM
SN
Nasal tip
protrusion
Radix
projection
Nose
bridge
length
N
Nasal
tip
Alar facial
groove
199
distance from the stomion to the menton (Fig.4.24a).
• Nasal height—Nasal height is the distance from the nasion superiorly to
subnasale inferiorly. It is measured by
placing the upper xed divider arm of
the vernier calliper with an accuracy of
0.01 cm on the nasion of the nose
superiorly and then the lower and
moveable divider arm on the subnasale
inferiorly. The reading was read on the
vernier scale and recorded (Fig.4.23c).
• Intercanthal distance—It is the distance between the two medial canthi of
the eye (Fig.4.23b).
• Dorsal aesthetic lines—These are
dened as two lines that connect the eyebrows to the tip of the nose. They originate on the supraorbital ridges, traversing
medially along the glabellar area, converging at the medial canthal ligaments,
diverging at the keystone area and terminating at the nasal tip. While there is not
an ‘ideal’ shape of the aesthetic lines, it
is important that they run essentially parallel through the bridge with a gentle
are as they run into the tip. They can be
straight, symmetrical or asymmetrical,
well or ill dened, narrow or wide. These
aesthetic lines should run smoothly.
Interruption or poor position of these
lines will cause the nose to look uneven
or disproportional.
• Nasal tip—The nasal tip is formed by
the two lower lateral cartilages or tip
cartilages and is the most projecting
part of the nose. The nasal tip of the
frontal view is analysed with regard to
symmetry and denition.
– Alar side wall—The normal side
alar walls are convex, concavity of
ala, alar notch, alar retraction.
200
4 History andExamination ofNose andPara Nasal Sinuses
– Bulbosity of tip—The tip lobule
width: alar width is calculated as
bulbosity index (B.I.). B.I. over 0.6
is dened as a bulbous tip. The bulbosity is measured in vertical and
horizontal aspects.
– Bidity of tip—It is cleft between
two nostrils of nose.
– Columella retraction (hidden
columella).
– Symmetry of alar insertion—Any
asymmetry is noted.
• Nasal (Nostril) width/breadth—The
nasal width can be assessed in upper,
middle and lower third of nose, separately. Nasal width is measured as the
distance between the external surface
of one ala to the other ala at right angle
to the nasal height from ala to ala. The
ideal width of the nose measured as
the alar base should be one-fth of the
total width of the face. A large tip lobule and wide alar bases can both give
the appearance of a disproportionately
large nose from an anterior view. A
wider alar base with ared alae is particularly common in Southeast Asian
and Afro-Caribbean noses.
(b) Lateral view (side view of nose) (Fig.
4.24):
• Radix projection—It is measured as
vertical distance between the corneal
and the radix plane and can be
expressed on the basis of ideal nose
length (Fig. 4.24c). Byrd and Hobar
proposed that this should be 0.28× the
ideal nose length. The radix extends
inferiorly from the nasion to the level
of a horizontal line passing through
the lateral canthi and superiorly from
the nasion for an equivalent distance.
The normal distance from the radix to
the inner canthus is 6mm and the distance between the corneal plane and
the radix plane is about 9–14mm. The
radix projection can be either normal
or abnormal (increased and reduced).
• Nasal dorsum projection (dorsal
projection)—Dorsal projection
describes the dorsum from its origin
on the face to its outermost point in
prole. Projection can be excessive,
with the dorsum extending too far off
of the face, or it can be insufcient, not
extending far enough off the face. The
cartilaginous and bony portions of the
dorsum must be examined separately,
as the projection of each may coincide
or differ. Either can be over projected,
under projected or normally
projection.
• Prole of dorsum (dorsal prole)—
The prole of the nose refers to the
shape of the outline of the bridge of
the nose. The bridge of the nose is
called the ‘dorsum’. The prole of the
dorsum is composed of the outline of
the nasal bones, the upper lateral cartilages and the nasal septum.
• Length of the nose dorsum—The
nasal bridge length is measured
between the soft tissue nasion to pronasale. The ideal nose length (RT) is
0.67× midfacial height. A straight
dorsum with no supratip break or a
straight dorsum reduced to a level of
2mm below the tip creating a retrousse
is both desirable.
• Columellar show—The columella is
the bridge of tissue that separates the
nostrils from the nasal tip to the nasal
base. The columellar show is an
assessment of how much of the inner
lining of the nostrils is visible in prole view. The ideal columellar show is
generally accepted to be between 2
and 4mm. Excessive columellar show
can be due to a variety of reasons, such
as a natural tendency towards hanging
columella and alar retraction, previous
rhinoplasty, trauma or a combination
of factors. It should be in the midline
but can be retracted, hanging, deviated
and broadened.
• Alar-columellar relationship (hang-
ing or retracted ala or columella)—
A line connecting the apex of the
nostril to its nadir divides the nostril
4.2 Examination ofNose andParanasal Sinuses
201
Fig. 4.25 Tip of nose
Supra tip
break
Double break
Ala columellar
relation
bb
aa
Nasal tip projection
Nasion
xxx
Alar
facial
groove
into equal halves. A retracted ala exists
when the distance from this line to the
alar rim is greater than 1.5–2 mm. A
hanging ala occurs when the distance
is less than 1.5–2mm.
• Nasolabial angle—It is dened as the
angle between the line drawn through
the midpoint of the nostril aperture and a
line drawn perpendicular to the Frankfurt
horizontal while intersecting sub-nasale.
An arbitrary range of 90°–120° for the
nasolabial angle is usually normal.
Acute—Due to hanging columella,
inferior rotation of tip, thick upper lip,
retrusive maxilla.
b-b- Nasal tip width
a-a- Inter extor width
Obtuse—Superior rotation of tip, thin
upper lip, protrusive maxilla.
(c) Tip/apex of nose: The apex of nose is
also known as tip of the nose. On either
side of the apex, the nostrils are formed
by the alae (singular = ala). An ala is a
cartilaginous structure that forms the lateral side of each naris (plural=nares) or
nostril opening. The philtrum is the concave surface that connects the apex of the
nose to the upper lip. The nasal tip should
ideally project from face and gracefully
lead the supratip dorsum, creating modest
supratip break (Fig.4.25).
202
• Type of nasal tip—Tip can be bullous,
bid, under-projected, tip ptosis or
over projected.
• Volume of tip—The size of the lateral
crura determines the volume of tip.
The too-convex lateral crus causes a
rounded tip and too long results in the
downward rotated tip.
• Tip denition—The denition implies
the degree of detail, renement and
angularity of the tip. It means giving
shape to the dome-dening point, columella break point and supratip break
point.
• Width of tip—The interdomal distance between two tip-dening points
determines the width of the nasal tip.
The excessive width is either due to
overprominance of lateral and middle
crural junction or excessive soft
tissue.
• Nasal tip projection/protrusion—The
nasal tip projection essentially means
how far out the tip protrudes from the
face when the prole is viewed. It is
measured as the distance from the alar
facial groove to the nasal tip. It should
be proportional to the nasal length
because nasal tip projection affects the
nasal tip rotation, dorsal height and
nasofacial aesthetic harmony. It is
measured by Goode’s method,
Crumley’s method and Byrd’s method.
The nose can be over projected or
under-projected.
Goode method—The nasal projection is
measured by drawing a line through the
alar crease which is perpendicular to the
Frankfort horizontal line. From there a
line is drawn to the nasal tip. An additional line is drawn from the nasal starting point (nasion) to the nasal tip.
Crumley’s methods—The nose with nor-
mal projection forms a 3–4–5 triangle
4 History andExamination ofNose andPara Nasal Sinuses
[i.e. alar point-to-nasal tip line (3), alar
point-to-nasion line (4), nasion-to-nasal
tip line (5)] (4).
Byrd’s methods—Tip projection is two-
thirds (0.67) of the planned post-operative (or the ideal) nasal length. The ideal
nasal length in this approach is twothirds (0.67) of the midfacial height.
• Tip rotation and derotation—It is
dened as the upward or downward
movement of the tip along a circular
arc consisting of a radius centred at the
alar creases extending to the tipdening point. Nasal tip rotation is
dened as the movement of the nasal
tip along an arc with a constant distance from the facial plane.
• Tip angle—It is formed between a vertical line passing through alar creases
and a second line from alar creases to
the tip. The normal tip angle is 105° in
female and 100° in male.
• Tip position—Tip position is dened
as the location of the tip along the dorsal line (nasion to tip).
• Supratip break—This break denes a
nose in which tip projection slightly
exceeds the prole line of the dorsum.
Anatomically, the supratip break is a
consequence of the projection differential between the domes of the lower
lateral cartilages and the dorsal septal
plane.
• Inter-alar width—It is the anatomical
width of the nose that connects the alar
curvature to alar curvature.
(d) Oblique view of nose: This view pro-
vides less information. The nasal bone
irregularities on the lateral aspect of nose,
nasal length, can be highlighted in this
view.
(e) Below/base of nose: On basal view, spe-
cial attention should be given to shape,
symmetry, columella/lobule ratio and
4.2 Examination ofNose andParanasal Sinuses
203
a
d
b c
e f
g h i
j
Fig. 4.26 Base of nose, (a) division of base of nose, (b) nasal oor width, (c) width of tip of nose and inter-alar width,
(d) external nasal valve and shape of nostril, (e) columellar width, (f–j) nasal base symmetry
width and insertion of alar base
(Fig.4.26).
• External nasal valve—The external
nasal valve is located in the area of
the nostrils and is limited in the lateral
direction by the caudal portion of the
alar cartilage with the connected soft
parts and in the medial direction by the
columella.
– Shape of external nasal valve/nos-
tril/nasal vestibule—Triangular,
elliptical, oval or round in shape.
– Size of nostril—Normal, narrow or
wide.
• Columella
– Columella width—The ideal colu-
mella starts at the apex of the nostrils with a width approximately
204
equal to that of the tip-dening
points. The columella then tapers
symmetrically reaching its narrowest width approximately at the
junction between the middle
one- third and lower one-third of the
height of the columella.
– Height or length of columella
– Position of columella
Retraction or under projection
Hanging or over projection
• Ala of nose—The ala of nose shows
great variability both among the individuals and from side by side in same
person.
– Alar collapse—Alar collapse and
contraction of the nasal tip are due
to the weakness of the lateral crus
of alar cartilage.
– Alar facial groove.
– Inter-alar distance.
– Alar thickness—The alar lobule
consists of three layers: external
skin, muscle and vestibular skin.
– Width of alar base—The normal
alar width generally falls within the
line dropped from the medial can-
thus of eye.
Flare (wide) ala—This is
attached directly to face.
Recovered ala—Ala is directly
attached to columella.
• Nasal sill—It is the distance between
the alar base and the columellar base.
• Nasal base shape—The general shape
of the nasal base has long been broadly
classied as the leptorrhine or long,
narrow nose, the mesorrhine or medium
nose and the platyrrhine or short broad
nose. The features of the Asian nose
from a basal view are usually of the
mesorrhine type, different from
Caucasian or African American noses.
• Nasal oor width—It is the distance
between subnasale and subalare.
• Symmetry of base of nose
4 History andExamination ofNose andPara Nasal Sinuses
Nasal outline symmetry
Alar base position symmetry
Nostril outline symmetry
Nostril axis symmetry
Columellar symmetry
Aesthetic analysis of nose
Frontal view of nose
Lateral or prole view of nose
Tip of nose
Base of nose
3. Deformities of external nose
(a) Deformities of dorsum of nose
• Deformities of position of dorsum
(deviated dorsum)
– Deviated nose—When the whole of
the dorsum deviates to one side
from the midline.
– Crooked nose (Fig.4.27)
Type of crooked
deformities Description
Type 1 Straight tilted bony pyramid with
tilted cartilaginous vault in opposite
direction
Type 2 Straight tilted bony pyramid with
concavely or convexly bent
cartilaginous vault
Type 3 Straight bony pyramid with tilted
cartilaginous vault
Type 4 Straight bony pyramid with bent
cartilaginous vault
Type 5 Straight tilted bony pyramid and
tilted cartilaginous dorsum in the
same direction
• Deformities of curvature of dorsum
of nose
C-shape dorsum
S-shaped dorsum
• Deformities of projection of dorsum
(on lateral view)
– Concave dorsum—Saddle nose and
supratip nose
Saddle nose—A saddle nose
deformity is most visibly charac-
4.2 Examination ofNose andParanasal Sinuses
205
Type IType II
Type IV Type V
Fig. 4.27 Deformities of the dorsum of nose
Fig. 4.28 Severity
(Grade 1 to Grade 4) of
saddle nose
Type III
terized by a loss of nasal dorsal
height. This deformity has also
been described as a pug nose or
boxer’s nose, both of which refer
to various degrees of nasal dorsal
depression. It involves bony and
cartilaginous vault (Fig.4.28).
Type 1—Minor supratip or nasal dorsal
depression, with a normal projection of
lower third of the nose
Type 2—Depressed nasal dorsum (moder-
ate to severe) with relatively prominent
lower third
Type 3—Depressed nasal dorsum (moder-
ate to severe) with loss of tip support
and structural decits in the lower third
of the nose
Type 4—Catastrophic (severe) nasal dorsal
loss with signicant loss of the nasal
structures in the lower and upper thirds
of the nose
206
bc
4 History andExamination ofNose andPara Nasal Sinuses
Fig. 4.29 Deformities
of projection of nose, (a)
Hump nose, (b) Long
nose, (c) Tension nose,
(d) Cleft lip nose, (e)
Short nose
a
d
Supratip depression—It is
dened as the depression cephalad to nasal tip, limited to cartilaginous part of dorsum caused
as a complication of septal haematoma and post-SMR.
– Convex dorsum—Hump nose,
long nose, high radix and tension
nose
– Wavy dorsum—Crooked nose
• Deformities of width of dorsum
– Wide dorsum
– Narrow dorsum
(b) Deformities of projection of nose:
• Over projected nose—Tension nose,
long nose, tension nose
(Fig.4.29a–c)
• Under-projected nose—Pushed in
dorsum, nose of cleft lip, small nose
(Fig.4.29d, e)
(c) Deformities of front of nose:
• Bony vault deformity—Narrow or
wide, asymmetrical, short or long
nasal bone
• Mid-vault deformity—Narrow or
wide, collapse, inverted V deformity
• Dorsal aesthetic lines deformity—
Straight, symmetrical or asymmetrical, well or ill dened, narrow or wide
e
• Nasal tip deformity—Bullous, boxy,
pinched supratip, tip-dening points,
infratip lobule
• Alar rim deformity—Gull shaped, facets, notching, retraction
• Upper lips deformity—Long or short
• Nasal dorsum deformity—Wide dorsum, twisted dorsum, deviated dorsum, narrow dorsum
• Height of nose—Reduced (saddle
nose) or increased (hump nose)
• Nasion (nasal starting point) deformity—High nasion and low nasion
• Nasal length deformity—Short or nose
(d) Deformities of radix of nose: It can be
either under or over-projected radix.
• Under projected/low—A low radix
position results in reduced nasal projection, increased tip projection and a
nasal base that appears larger than its
actual size. The nose appears disproportionately short with a deep (<130°)
nasofrontal angle.
• Over projected/high—The nasofrontal angle is shallow (>145°), and it
appears long with the nose and forehead lying in a straight line. In
patients with a high radix, the radix
projection is above the normal limit,
4.2 Examination ofNose andParanasal Sinuses
207
such that the nose appears excessively
long. In the prole view, the nose-toforehead angle may be wide, such
that the nose and forehead appear
continuous, an effect known as ‘avatar nose’.
(e) Deformities of lateral wall of nose: The
deviated lateral wall of the nose, concave lateral wall, convex lateral wall.
These signs are common in fractured
nasal bone.
(f) Alar-columella relationship deformity:
This deformity is either due to ala or
columella.
Alar deformity—Alar retraction or
hanging deformity
Columella—Retraction or hanging
deformity
(g) Nasolabial angle deformities:
Acute—This is associated with a
downturn tip, pollybeak deformity, long
nose, cleft lip nose
Obtuse—This is associated with
upturn tip and short nose
(h) Deformities of tip of nose:
• Deformities of types of nasal tip
– Bid tip—Alar cartilages are
placed apart and prominently convex, so a dimple appears between
them.
– Bulbous tip—It has prominent and
high-volume alar cartilage and light
reex on the lateral border of alar
cartilage instead of the tip point.
– Boxy tip—It has a broad, rectangu-
lar shape, especially on a basilar
view. It is of three types.
Type 1—Increase divergence angle >30°
with normal domal arc 4mm or less
Type 2—Normal angle of divergence 30°
or less with wide domal arc
Type 3—Increase angle of divergence with
wide domal arc
– Ball tip—The large convex carti-
lage gives the tip a round and circular appearance on the anterior view.
– Parenthesis tip—This is due to the
malposition of the alar cartilages. A
cephalically oriented bulbous lateral
crura typically creates a parenthesis
appearance on the frontal view.
– Bulky tip—It is characterized by
thick skin with a heavy nasal base
which is imbalanced with the rest
of the nose.
– Sharp/pointy tip—A pointy nose is
often the result of projecting nasal
septum cartilage or excess cartilage
at the tip of the nose.
• Nasal tip projection deformities
– Under-projected deformity—An
under-projected nasal tip is a nose
where the tip sits too closely to the
face resulting in a attened
appearance.
Drooping tip (nasal tip ptosis)—
When the tip of the nose is more
caudal than what is deemed
ideal It is down-turned tip. A
drooping nasal tip can be caused
by many factors. The most common among them include too
much cartilage around the nose,
ageing, lack of cartilage rmness and even traumatic accidents. Also, muscle pull at the
nasal tip may cause a drooping
appearance. A ptotic nasal tip
may be otherwise described as
underrotated. Thus, the terms
ptotic and underrotated as
applied to the nasal tip are used
interchangeably. Pseudo-tip ptosis is caused by nasal hump.
Crooked nose—This is nose
with deviated dorsum and underprojected nasal tip.
Hump nose—This is nose with
elevated dorsum and underprojected nasal tip.
208
4 History andExamination ofNose andPara Nasal Sinuses
Short nose—The classic short
nose is upturned and depressed.
More specically, it is dened as a
nose lacking dimension from the
nasofrontal angle to the tip. Three
classied types of short noses in
frontal view and side view.
Marginal type—Short nose with short
nasal tip and alar retraction
Basal type—Short nose with short nasal
tip and columellar retraction
Severe short nose—Severe short nose
with short tip, columellar retraction and
alar retraction
– Over-projected deformity—The
over- projected nasal tip, also termed
‘Pinocchio nose’, is a nose
where the tip lies too far away
from the face. However, the
underdevelopment of adjacent
structures may result in an
over-projected appearance to the tip
(pseudo-over- projection) (Fig.4.30).
Over-projected tip—If a tip is
sticking out too far from the
Fig. 4.30 Deformities of the nasal tip
face, it is known as over overprojected nose.
Pinched tip—A pinched nose
means a permanent sinking of
the vestibular wall, obstructing
the nostril and creating an unesthetic alar groove on one or both
sides. It can be either congenital
or acquired. The acquired
pinched nose is due to botched
nose job during which an excessive amount of cartilage was
removed from tip of nose.
Long nose—It is long nose with
an over-projected tip.
Bullous tip—It is described
when the nasal tip is excessively
heavy.
Tension nose—It is dened as
nose with high nasal dorsum and
anterior and sometimes inferior
displacement of the nasal tip
cartilages. Tension deformity is
due to excessive growth of the
quadrilateral cartilage.
• Deviated tip—The deviated tip is
associated with a crooked nose or
deviated nose or caudal dislocation of
the septum or deviated nasal septum.
• Supratip deformity—It is previously
called the ‘polly beak’ or ‘parrot beak’
deformity and is dened as fullness or
convexity immediately cephalad to the
nasal tip, which may occur as a primary (congenital) or a secondary
(post-rhinoplasty or submucosal resection (SMR)) deformity.
• Nasal tip support and recoil—The
loss of recoil and nasal tip support.
• Columellar show—The columella
can be hanging columella or retracted
columella.
• Ala of nose—The ala can be retracted
ala, hanging ala.
(i) Deformities of base of nose:
• Nostril width deformities/alar base
width deformities
– Narrow nostril width—Pinched nose
– Increase nasal width—Wide nose