The nose is remarkable in its variability, in profile, frontal plane, and from the undersurface. Details and definitions of the soft tissue and bony landmarks are available in references at the end of this chapter and are illustrated in Fig. 7.65a. A qualitative assessment of the nose should include:
1. the nasofrontal angle: is it normal, flat, or deep;
2. the nasal root protrusion: is it average, high, or low;
3. the nasal bridge: is it high, low, broad, beaky, or bulbous;
4. the nasal tip: is it normal, flat, or bifid;
5. the shape of each nasal ala: is it normal, slightly flat, markedly flat, slightly or markedly angled;
6. the nasal ala configuration: is it cleft, hypoplastic, hyper-trophic, and is there a coloboma;
7. the type and size of the nostrils: are they symmetric, asymmetric, and what type are they according to the Topinard classification (Fig. 7.65b).
The Topinard classification describes seven types of nostrils, three of which are intermediate (Fig. 7.65b). Type 7 is characteristic of nostrils in patients with a repaired cleft lip. More than half of the general population have Type 2 nostrils; a quarter have Type 1 nostrils, the other types being less frequent. The Topinard classification outlines some of the variability in size and shape of the alae nasi, nares, and columella.
Common variations in nose shape are shown in Fig. 7.65c. Attempts to quantify changes in nose shape with age have rarely been documented. However, it is well known that the nasal root is depressed in the infant and young child, associated with a scooped-out nasal bridge. With increasing age, the nasal bridge rises, producing a more prominent root. Nostril type also varies with age. The prevalence of Topinard Type 4 decreases significantly after age 18.
Most nasal measurements are soft tissue measurements. However, many alternatives are available from radiographs. These will not be described in detail here, and the interested reader is referred to the literature cited at the end of this chapter.
The horizontal measurements of the nose, particularly the width of the nasal root and the interalar distance, provide information about midline development in the same way that the measurements of eye spacing reflect midline development. The nasal tip may be broad, grooved, cleft,
or actually bifid with increasing width of the nose. A bifid nose results when the medial nasal prominences do not merge completely. In this situation, the nostrils are widely separated and the nasal bridges is bifid. This type of malformation may be part of a spectrum known as frontonasal dysplasia.
Unlike most vertical facial dimensions, nasal length continues to increase throughout life.
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