Saddle Nose Deformity: Causes, Diagnosis, and Treatment

Saddle-Like Boxer Nose!

Definition of Saddle Nose Deformity

It is a deformity which is characterized by the collapse of the nose dorsum, also known as "boxer nose", which can affect the aesthetic and functional properties of the nose. Generally, the length of the nose is shortened and when viewed from the side, there is a collapse just above the tip of the nose due to a decrease in the supporting tissues of the nose and a saddle on the upper side.

Properties of saddle nose deformity

Descriptive properties of saddle nose deformity:

† Depression in the dorsum of the nose
† Reduction of nasal tip support or complete loss of support tissues
† Shortened vertical nose tip length
† Extreme rotation at the nose tip
† Retrusion in the lower part of the nasal septum (caudal part)

Image description u on the left: The nose photograph of a female patient, who had a previous nasal trauma and then developed a saddle nose deformity after a septoplasty operation in another clinic, is shown.

I am adding photos of former welterweight boxing champion "Ferdinand Henry John Zivcich".

You can see how his nose change over the years and after the matches on the internet. Photographs typically show traumatic saddle nose deformity characteristics.

Causes of Saddle Nose Deformity

Saddle nose deformity may be due to congenital or acquired causes. Various degrees of nasal dorsal depression can be noticed as part of individual familial, syndromic, and racial features. In many patients, this deformity occurs due to the causes of postpartum. The most common causes are traumatic and iatrogenic (depending on the surgical procedure). The patient who was seen in the photograph was performed septoplasty at another clinic twice and was admitted to our clinic because of saddle nose deformity.

Several factors can contribute to the development of saddle nose deformity. The condition often results from damage to the nasal septum or the nasal bridge, leading to a loss of structural support.

The causes of saddle nose deformity can be listed as follows:

Nasal Trauma

One of the most common causes of saddle nose deformity is trauma to the nose. Injuries, such as those sustained in sports, accidents, or physical altercations, can damage the nasal cartilage and bone. Over time, if the trauma is severe enough, the nasal bridge may collapse, leading to the characteristic saddle-like appearance. The cartilage and bone structures that provide trauma to the nose can be broken or the septal hematoma may cause the formation of septal abscess and indirectly the formation of the saddle nose.

Septal Hematoma

A septal hematoma, which occurs when blood collects between the layers of the nasal septum following an injury, can lead to cartilage death (necrosis) if left untreated. This loss of cartilage can contribute to the collapse of the nasal bridge and the development of saddle nose deformity.

Septal Perforation

Septal perforation is a hole in the nasal septum, which can result from surgery, trauma, or other conditions. The perforation weakens the structural support of the nose, leading to collapse over time. In many cases, septal perforation and saddle nose deformity go hand-in-hand, especially after previous nasal surgeries or trauma.

Infection

Severe nasal infections can damage the cartilage and tissue within the nose, leading to deformities. Conditions like syphilis, tuberculosis, or leprosy have historically been associated with saddle nose, though they are less common causes today.

Autoimmune Diseases

Autoimmune diseases like Granulomatosis with Polyangiitis (formerly known as Wegener's Granulomatosis) or lupus can cause inflammation and destruction of the nasal cartilage. In these cases, the body’s immune system mistakenly attacks its own tissues, leading to cartilage loss and nasal bridge collapse.

Cocaine Use

Prolonged use of cocaine can damage the blood vessels and tissues within the nose, leading to septal perforation and eventual saddle nose deformity. Cocaine's corrosive effect on the nasal mucosa can cause significant structural damage over time.

Iatrogenic Causes (Surgical Complications)

In case of rhinoplasty surgery and septoplasty operation, saddle-nose deformity may occur due to the formation of warts or removal of excess cartilage in the rhinion region between the septum and the nasal bone. Nasal surgeries, such as septoplasty or rhinoplasty, can sometimes result in saddle nose deformity, particularly if too much cartilage or bone is removed during the procedure. This is why choosing an experienced surgeon is crucial for those considering nasal surgery.

Treatment of Saddle Nose Deformity

The goal in the treatment of saddle nose is to reshape the nose and at the same time to restore its functional properties. Various grafts may be used according to the degree of damage and deformity present.

Grafts and materials that can be used for this purpose:

† Rib cartilage

† Ear bucket cartilage

† Irradiated cartilages and decellular skin obtained from cadavers

† Titanium based materials

† Silicone based materials

† Temporal muscle fascia

When ribs and ear glands are taken from the patient's body, foreign body reactions, tissue reactions, allergy and infection are less likely than others. Taking cartilage of the ribs is more difficult than taking earworm cartilage. I usually use the ear-cartilage cartilage as the first choice. I prefer to take rib cartilage in large deformities where cartilage of the ears is not enough.

The photographs of the patient with septum perforation and saddle nose deformity that occurred after a traumatic septum surgery performed years ago in a different clinic are shown above.

In the above picture, preoperative and postoperative photograph of the cartilage taken from the rib is seen in the patient with advanced saddle-nose deformity which is due to previous traumatic injury to the nasal bone and nasal cartilage.

Temporary Non-Surgical Solutions 

For patients who are not ready or eligible for surgery, temporary non-surgical options like dermal fillers can be used to improve the appearance of the nose. Fillers, such as hyaluronic acid, can be injected into the nasal bridge to provide temporary volume and correct the saddle-like appearance. However, these treatments do not address the underlying structural issues and typically last only six months to a year.

Treatment for Underlying Conditions 

In cases where saddle nose deformity is caused by an underlying condition, such as an autoimmune disease or infection, treating the root cause is essential. For instance, if the deformity is caused by Granulomatosis with Polyangiitis, the patient may need to undergo immunosuppressive therapy to control the disease and prevent further damage to the nasal cartilage. Similarly, if the condition is caused by an infection, antibiotics or antiviral medications may be necessary.

New Study Emphasized The Risk Factors For Intraoperative Saddle Nose Deformity In Septoplasty Operation!

New study that published in  Journal of European Archives of Oto-Rhino-Laryngology emphasized that "severe caudal septal deviation, intraoperative fracture of septal cartilage, and female gender are risk factors for intraoperative saddle nose deformity in septoplasty patients". Minimal traumatic techniques and preservat,on of nasal septum cartilage can prevent to appearing of this nose deformity.

Study link >> Risk factors for intraoperative saddle nose deformity in septoplasty patients

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul

Private Office:

Address: İncirli Cad. No:41, Kat:4 (Dilek Patisserie Building), Postal code: 34147, Bakırköy - İstanbul
Appointment Phone: +90 212 561 00 52

E-Mail: muratenoz@gmail.com
Mobile phone: +90 533 6550199

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