Evaluation of Postoperative Results in Patients with Functional and Aesthetic Septorhinoplasty

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Габриела Копачева-Барсова


The objectives of the surgical technique septorhinoplasty are to remodel and redesign the nose, to remove the excessive bone and cartilaginous structures, and/or to correct the nasal insufficiencies in order to obtain a harmonious proportion of the nose in regards to the other facial structures. Furthermore, septorhinoplasty is one of the most frequently used aesthetic-surgical otorhinolaryngological procedures. The cartilaginous part of the nasal septum is an integral part of the isthmus's region and has a significant role in the air's circulation and turbulence. Due to this central role of the nasal septum, it is of crucial importance to undertake an adequate surgical technique since it is the key for a successful treatment both in the functional, and the esthetic rhinosurgery. The deformities of the nasal septum might be localized in the bone or in the cartilaginous structures, but most often, they are present in both of the structures. The cartilaginous deviations are the ones which are most responsible for the obstruction of the nasal respiratory flow. For that reason, they have been adequately classified. In this in-depth study, the aims have been:
1. To objectify the nasal air resistance (nasal obstruction) using rhinomanometry while selecting patients for septorhinoplasty.
2. To evaluate the frequency and the intensity of the nasal symptoms in patients that are about to undergo septo/rhinoplasty, before and after the intervention.
3. To classify the deviations of the nasal septum in regards to the septal structural and anatomical changes based on the CT of the nose and the paranasal sinuses and on the intrasurgical findings.
4. To determine an adequate psychological personality model while selecting patients for septo/rhinoplasty.
Confirmed by clinically relevant data, the goal of this study has been to ensure its acceptance and implementation as a protocol for selecting patients for septo/rhinoplasty. The author points out that this is a prospective, as well as non-randomized study where a statistical analysis has been conducted on a total of 140 patients experiencing deviations of the nasal septum (deviatio septi nasi) separate from or along with the deformities of the nasal pyramid: rhinokyphosis, rhinoscoliosis, rhinolordosis ("saddle nose"), and "functional tension nose". The examined patients were added on the list for surgical septo/rhinoplasty procedures performed at the ENT Clinic at University Hospital in Skopje, during the period of September, 2008 till September, 2013. The rhinomanometry examinations were performed at the Institute of Occupational Medicine in Skopje, while the psychological tests were carried out with the assistance of a clinical psychologist and a psychiatrist at the Psychiatry Clinic at University Hospital in Skopje. The examined groups were divided according to the following parameters:
a) According to the degree of nasal obstruction, the patients were divided into 3 groups:
Group IA – patients with a severe degree of nasal obstruction (severe degree of nasal resistance).
Group IB – patients with a moderate degree of nasal obstruction (moderate degree of nasal resistance).
Group II – patients with a mild degree of nasal obstruction (mild degree of nasal resistance), clinically monitored for a year, and then agreed upon to undergo surgical intervention.
In all patients candidates for septo/rhinoplasty, nasal symptoms such as: nasal obstruction, rhinorrhea, nasal pain, headache, hyposmia, snoring, nasal voice, epistaxis and others were pre-surgically monitored. After the surgical intervention, a survey was conducted in order to find out how satisfied the patients were after the performed correction. The patients were offered with 5 scores, that is, 5 modalities: 1 – very satisfied, 2 – satisfied, 3 – undecided, 4 – dissatisfied and 5 – extremely dissatisfied.
b) According to the type of surgical technique applied while performing the surgical intervention, the patients were divided into two groups:
- group I – 1: in which septoplasty was performed; the group was constituted of patients with Dg. Deviatio septi nasi.
- group I – 2: in which septorhinoplasty was performed: the group was constituted of patients who besides nasal septum deviation, also had some deformity of the nasal pyramid, such as: rhinokyphosis, rhinoscoliosis, rhinolordosis ("saddle nose"), and "functional tension nose".
These two groups were then divided into two subgroups:
- subgroup I2-a: in which lateral and medial osteotomy was performed
- subgroup I2-b: in which osteotomy was not performed.
c) Psychological analysis was performed solely on patients candidates for septorhinoplasty who voluntarily accepted to fill in the questionnaire for selection of patients candidates for septorhinoplasty and assessment of their psychological predispositions. Based on a numerous world standardized tests and questionnaires that would be applicable to the patient candidate for intervention, a similar questionnaire, adapted to our region was devised, in which the following parameters were included: Selecting a patient for septo/rhinoplasty and assessing their psychological predispositions (Psychological testing – a questionnaire for self body image), Brief Symptom Inventory Test (BSI) with which an analysis was carried out on the acquired results of the questions posed to the patients candidates for septo/rhinoplasty. Through the Brief Symptom Inventory (BSI) test, which is a standard psychological test, the following psychological symptoms in patients were recognized: somatization, obsessive-compulsive reactions, interpersonal sensibility, depression, anxiety, phobic anxiety, and paranoid ideas. There have also been patients who have not displayed any of these symptoms. The methods used throughout the examination are rhinomanometry, as a method for objectifying the nasal air resistance and computed tomography of the nasal and paranasal sinuses. The examined nasal symptoms were then recorded and grouped in the scale of subjective nasal symptoms.
Intraoperatively, the structural deformities of the nasal septum were classified into six groups. The psychological tests for selecting patients for septorhinoplasty and assessing their psychological predispositions were carried out by means of specific questionnaires. Therefore, a surgical protocol was established, as well as surgical procedures and actions needed for septo/rhinoplasty. Throughout the examination, the PhD candidate had not strictly held close to one rigid course of action or another while performing esthetic or functional rhinosurgery. The surgical procedure performed at a particular case rather depended on the pathology of the septum. The statistical methods used for the analysis of the obtained results are also listed. Based on the results, the statistical processing, as well as through discussion, the following conclusions have been drawn:
1. Rhinomanometry is a method that objectively determines the degree of nasal obstruction. It is clinically a very important method because it provides a pre-surgical real objectification of the degree of nasal obstruction. In the study, the use of rhinomanometry was beneficial since it attained the clinical objective to distinguish and group the patients who were truly in need of septo/rhinoplasty and the patients that were supposed to be monitored and receive medicament treatments. Likewise, the study brought about evidence that there is indication for septoplasty in patients with mild degree of nasal resistance (mild deviation of the nasal septum which even though monitored for a year, without use of drugs/medicine or topical nasal steroids, was still present, therefore the need of septoplasty was unavoidable.In many patients that are in a need of both functional, and aestethetic-functional septorhinoplasty the open question is posed of whether there is a connection between the degree of nasal obstruction, the incidence and the intensity of the occurrence of nasal symptoms that are a result of the deviated nasal septum. Admittedly, it has been expected that most of these patients would suffer from asymmetrical nasal flow through the nostrils due to the deviation of the nasal septum and if the deviation of the nasal septum is more severe and the nasal resistance is greater, then the nasal symptoms are prominent which has led to one-sided or double sided hypertrophy of the nasal cavity.
2. The feeling of impaired breathing was described by the patients candidates for septo/rhinoplasty as a dominant symptom of nasal obstruction. The results from the research have demonstrated that pre-surgically, as well as during the check-ups in 3, 6 and 12 months, the patients who experienced mild nasal obstruction that had not posed a problem in their everyday life and sleep were the fewest. Listing headache as a predominant symptom in patients with nasal septal deviation and its constancy in the post-surgical period showed that the headache is also caused by certain subjective reasons most commonly of psychogenic nature, such as anxiety, restlessness and great expectations of the intervention. The rhinorrhea was drastically diminished as a result of the correction of the nasal septum that reduced the edema and the hypertrophy of the nasal mucosa, especially the changes in the nasal concha, which has led to the decrease of the exudation of the nasal secretion. The occurrence of epitaxis was detected along the nasal septal deviations in the front and front-back sections, but it was of no significance. Therefore, it was inferred that all other causes that might be of functional, inflammatory, subjective or other nature might bring about the occurrence of these symptoms. 3. The results showed the significant correlation between the anatomical (objective) and the psychological (subjective) causes that determined the frequency and the intensity of the occurrence of the nasal symptoms. An analysis was made on the classifications of the nasal septal deviations on Mladina, as well as on the classification based on the coronal transections of the nasal septum acquired by coronal and axial transections of the nasal septum obtained with computed tomography. Likewise, a comparison was made in regards to the correlation between the nasal deviation and the consequent changes in the middle nasal cavity by comparing the examinations with the ones performed by Baumann and associates in the study of classification of the nasal septal deviation. The systematic classification of the deviations of the nasal septum done in this study has a lot of advantages compared to the other previously mentioned classifications because the previously mentioned ones mostly encompassed the classifications in the region of the cartilaginous septum, without taking into account the role that the position of the nasal septum has in regards to the external configuration of the nose. The objective of this classification is to encompass all the pathological alterations of the nasal septum and to document them, in order to implement an adequate surgical technique. Other objectives of this classification are to make the systematic training of young rhino surgeons in septoplasty easier, as well as to make this occupation more interesting and more appealing.In the chapter on the Surgical Protocol during septo/rhinoplasty, the surgical procedures and actions while performing a surgical intervention of septo/rhinoplasty were determined and established.
4. Through several surgical techniques, one modern approach to performing the surgical technique septoplasty was demonstrated. The ultimate objective of this surgical procedure was to indicate that not only a medial location of the nasal septum, but also a medial location of the space between the septum and the nasal cavities was of vital importance for a proper nasal respiration. The motto as well as the benefit of an adequately performed intervention in septal surgery and surgery of the nasal concha is: "Not the septum, nor the nasal concha, but the space between them is the point".
5. By testing the psychological profile of a patient's personality, the idea was that the patient would come to a mature decision by being fully aware of the possible change that would take place and would change their life, not only physically, but spiritually as well. This would also be beneficial to the surgeon in making the right decision regarding the surgical course of the intervention; it would also be of great use in the post-surgical clarification of the objective expectations of the surgeon by the performed surgical procedure and the expectations of the patient.
Last but not least, a maxim that sums up the importance of experience.


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Копачева-Барсова Г. Evaluation of Postoperative Results in Patients with Functional and Aesthetic Septorhinoplasty. Maced Med Electron J [Internet]. 2014 Jun. 21 [cited 2023 Dec. 6];1(1):1-164. Available from: https://www.id-press.eu/mmej/article/view/mmej.2015.50001
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Krouse JH. The unified airway--conceptual framework. Otolaryngol Clin North Am. Apr 2008;41(2):257-66. DOI: https://doi.org/10.1016/j.otc.2007.11.002

Bagheri SC. Primary cosmetic rhinoplasty. Oral Maxillofac Surg Clin North Am. 2012;24:39-48. DOI: https://doi.org/10.1016/j.coms.2011.10.001

Tardy ME Jr, Thomas JR. Rhinoplasty. In: Flint PW, Haughey BH, Lund VL, et al., eds. Cummings Otolaryngology: Head & Neck Surgery. 5th ed. Philadelphia, PA: Elsevier Mosby; 2010:chap 45. DOI: https://doi.org/10.1016/B978-0-323-05283-2.00037-9

Orahilly R, Muller F, Carpenter S, Swenson R. The nose and paranasal sinuses. Chapter 52. Basic Human Anatomy. R Swenson, Ed. DartmouthMedical School. 2008. [cited 31 January 2012].

Mann MD. Gustatory and Olfactory senses. Chapter 10. The nervous system in action. [online]. 2008. University of Nebraska Medical Centre. [cited 26 January 2012]

Des Jardins TR. The anatomy and physiology of the respiratory system. Chapter 1. Cardiopulmonary anatomy and physiology- Essentials of Respiratory Care. Edition 5. 2008; pp3-66.

Dykewicz MS. Rhinitis and sinusitis. J Allergy Clin Immunol. 2003; 111: S520-9.] DOI: https://doi.org/10.1067/mai.2003.82

Pawankar R, Mori S, Ozu O, Kimura S. Overview of the pathomechanisms of allergic rhinitis. Asia Pac Allergy. 2011; 1(3): 57-67. DOI: https://doi.org/10.5415/apallergy.2011.1.3.157

Van Cauwenberge PB. Nasal sensitisation. Allergy. 1997; 52(33-Supp): 7-9. DOI: https://doi.org/10.1111/j.1398-9995.1997.tb04797.x

Baroody FM, NaclerioRM.Nasal-ocular reflexes and their role in the management of allergic rhinoconjunctivitis with intranasal steroids. World Allergy Org J. 2011; 4(1): S1-Ghaffar A. Hypersensitivity reactions. Chapter 17. Microbiology and immunology. [online]. University of South Carolina. 2010. [cited 26 January 2012]. DOI: https://doi.org/10.1186/1939-4551-4-S1-S1

Wexler DB, Davidson TM. The nasal valve: a review of the anatomy, imaging, and physiology. Am J Rhinol. May-Jun 2004;18(3):143-50. DOI: https://doi.org/10.1177/194589240401800303

Naclerio RM, Pinto J, Assanasen P, Baroody FM. Observations on the ability of the nose to warm and humidify inspired air. Rhinology. Jun 2007;45(2):102-11.

Leong SC, Chen XB, Lee HP, Wang DY. A review of the implications of computational fluid dynamic studies on nasal airflow and physiology. Rhinology. Jun 2010;48(2):139-45. DOI: https://doi.org/10.4193/Rhin09.133

Liu T, Han D, Wang J, Tan J, Zang H, Wang T, et al. Effects of septal deviation on the airflow characteristics: Using computational fluid dynamics models. Acta Otolaryngol. Mar 2012;132(3):290-8. DOI: https://doi.org/10.3109/00016489.2011.637233

Ballenger JJ. Diseases of the Nose, Throat, Ear, Head and Neck. 13th ed. Lippincott Williams & Wilkins; 1985. DOI: https://doi.org/10.1097/00006534-198512000-00035

Clement PA. Committee report on standardization of rhinomanometry. Rhinology. Sep 1984;22(3):151-5.

Cole P. Biophysics of nasal airflow: a review. Am J Rhinol. Jul-Aug 2000;14(4):245-9. DOI: https://doi.org/10.2500/105065800779954383

Ingelstedt S. Studies on the conditioning of air in the respiratory tract. Acta Otolaryngol Suppl. 1956;131:1-80.31

Loehrl TA. Autonomic function and dysfunction of the nose and sinuses. Otolaryngol Clin North Am. Dec 2005;38(6):1155-61. DOI: https://doi.org/10.1016/j.otc.2005.08.004

Selimoglu E. Nitric oxide in health and disease from the point of view of the otorhinolaryngologist. Curr Pharm Des. 2005;11(23):3051-60. DOI: https://doi.org/10.2174/1381612054865037

Scadding G. Nitric oxide in the airways. Curr Opin Otolaryngol Head Neck Surg. Aug 2007;15(4):258-63. DOI: https://doi.org/10.1097/MOO.0b013e32825b0763

Taylor M, Shores SC. Heat exchange in the nose. Laryngoscope. Oct 1981;91(10):1606-13. DOI: https://doi.org/10.1288/00005537-198110000-00004

Basic N, Basic V, Jukic T, et al. Computed tomographic imaging to determine the frequency of anatomical variations in pneumatization of the ethmoid bone. Eur Arch Otorhinolaryngol 1999;256:69–71 DOI: https://doi.org/10.1007/s004050050118

Perez P, Sabate J, Carmona A, et al. Anatomical variations in the human paranasal sinus region studied by CT. J Anat 2000;197:221–227 DOI: https://doi.org/10.1017/S0021878299006500

Zinreich SJ, Mattox DE, Kennedy DW, et al. Concha bullosa: CT evaluation.J Comput Assist Tomogr 1988;12:778–784 DOI: https://doi.org/10.1097/00004728-198809010-00012

Zinreich S, Abidin M, Kennedy D. Cross-sectional imaging of the nasal cavity and paranasal sinuses. Operative Techniques Otolaryngol Head Neck Surg 1990;1:93–99 DOI: https://doi.org/10.1016/S1043-1810(10)80033-8

Nasology Eden Warwick, 1848

American Society for Aesthetic Plastic Surgery. 2011 Plastic Surgery Statistics Report. American Society for Aesthetic Plastic Surgery. Available. Accessed March 21, 2012.

AAFPRS. 2011 AAFPRS Membership Survey. AAFPRS. Available. Accessed March 21, 2012.

Powell, N. and Humphreys, B. Proportions of the Aesthetic Face. New York, N.Y.:Thieme-Stratton; 1984.

Farkas LG. Linear Proportions in Above- and Below-Average Women's Faces. In: Anthropometric Facial Proportions in Medicine. Springfield: Thomas; 1987:119-29.

Singh D. Ideal female body shape: role of body weight and waist-to-hip ratio. Int J Eat Disord. Nov 1994;16(3):283-8. DOI: https://doi.org/10.1002/1098-108X(199411)16:3<283::AID-EAT2260160309>3.0.CO;2-Q

Hengerer AS, Oas RE. Congenital anomalies of the nose: Their embryology, diagnosis, and management (SIPAC). Alexandria, Va: American Academy of Otolaryngology; 1987.

Jafek BW. Anatomy and physiology of the nose. In: Jafek BW, Stark AK, eds. ENT Secrets. Philadelphia, Pa: Hanley & Belfus; 1996:77-83.

Heidari Z, Mahmoudzadeh-Sagheb H, Khammar T, Khammar M. Anthropometric measurements of the external nose in 18-25-year-old Sistani and Baluch aborigine women in the southeast of Iran. Folia Morphol (Warsz). May 2009;68(2):88-92.

Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. Aug 1985;76(2):239-47. DOI: https://doi.org/10.1097/00006534-198508000-00010

Boenisch M, Hajas T, Nolst Trenité GJ: Influence of Polydioxanone Foil on Growing Septal Cartilage in an Animal Model. New Aspects of Cartilage Healing and Regeneration. Arch Facial Plast Surg 2003; 5: 316-319 DOI: https://doi.org/10.1001/archfaci.5.4.316

Boenisch M, Nolst Trenité GJ: Rhinoplasty. A practical guide to functional and aesthetic surgery of the nose. 3rd edition. Kugler Publications, The Hague, The Netherlands, 2005; Chapter 25: 257-284 32

Nolst Trenité GJ: Grafts in Nasal Surgery. In Rhinoplasty.A practical guide to functional and aesthetic surgery of the nose. 3rd edition. Kugler Publications, The Hague, The Netherlands, 2005; Chapter 7: 49-67

Boenisch M, Nolst Trenité GJ, Septal Reconstruction using PDS plate. Arch Facial Plastic Surg 2010;12: 4-10 DOI: https://doi.org/10.1001/archfaci.2009.103

Spí¶rri S, Simmen D, Briner HR, Jones N: Objective Assessment of the nasolabial angle in rhinoplasty. Arch Facial Plast Surg 2004; 6: 295-300 DOI: https://doi.org/10.1001/archfaci.6.5.295


Aschan G, Drettner B, Ronge H (1958) A new technique for measuring nasal resistence to breathing, illustrated by the effects of histamine and physical effort. Ann Acad Reg Sci Ups 2:11-126

Wengraf Cl, Gleeson MJ, Siodlak MZ (1996) The stuffy nose: a comparative study of two common methods of treatment. Clin Otolaryngol 111: 61-68 DOI: https://doi.org/10.1111/j.1365-2273.1986.tb00109.x

Vainio- Mattilla J (2007) Correlation of nasal symptoms and signs in random sampling study. Thesis, University of Turky. Acta Otolaryngol Suppl (Stockh) 318: 1-48 DOI: https://doi.org/10.3109/00016487409129567

Broms P, Jonson B, Malm I. (1982) Rhinomanometry II. A system for numerical description of nasal airway resistance. Acta Otolarynolo (Stockh) 94:157-168 DOI: https://doi.org/10.3109/00016488209128900

Cole P, Chaban R, Naito K (2000) The obstructive nasal septum. Arch Otolaryngol Haed Neck Surg 114: 410-412

Dommerby H, Rasmussen O, RosborgJ (2002) Long Term results of septoplastic operations. ORL. J Otorhinolaryngolo Relat Spec 47: 151-157 DOI: https://doi.org/10.1159/000275761

Fordon A. McCaffrey T, Kern E, Pallanch J (1999) Rhinomanometry for preoperative and postoperative assessment of nasal obstruction. Otolaryngol Haed Neck Surg 101:20-26

Jessen M. Malm I. (2004) The importance of nasal airway resistance and nasal symptoms in the selection of patients for septoplasty. Rhinology 47: 157-164

Mertz J, McCaffrey T, Kern E (2006) Objective evaluation of anterior septal surgical reconstruction. Otolaryngol Haed Neck Surg 92:308-311 DOI: https://doi.org/10.1177/019459988409200312

Mygind N (1994) Nasal allergy, 3th Edition. Blackwell, OxfordSipila J, Suonpaa J, Salmivalli A, Laippala P (2001) The effect of the nasal cycle on the interpretation of rhinomanometric results in nasal provocation test. Am J Rhinol 4: 179-184 DOI: https://doi.org/10.2500/105065890782009442

Sipila J, Suonpaa J, Salmivalli A, Laippala P (2004) Rhinomanometry before septoplasty. An approach to clinical material with diverse nasal symptoms. Am J Rhinol 6: 17-22 DOI: https://doi.org/10.2500/105065892781976736

Suonpaa J, Sipila J, Salmivalli A, Laippala P (2001) Do rhinomanometric findings predict subjective postoperative satisfaction? A long term follow-up after septoplasty Am J Rhinol 12: 71-75 DOI: https://doi.org/10.2500/105065893781976500

Bohlin L, Dahlqvist A (1994) Nasal airway resistance and complications following functional septoplasty: A ten-year follow-up study. Rhinology 32:195-197

Yahyavi S, Parsa FM, Fereshtehnejad SM, Najimi N. Objective measurement of nasal airway dimensions and resistance using acoustic rhinometry and rhinomanometry in habitual snorers compared with non-snorers. Eur Arch Otorhinolaryngol. 2008 Dec; 265(12):1483-7. Epub 2008 DOI: https://doi.org/10.1007/s00405-008-0673-1

Haarmann S, Budihardja AS, Wolff KD, Wangerin K. Changes in acoustic airway profiles and nasal airway resistance after Le Fort I osteotomy and functional rhinosurgery: a prospective study. Int J Oral Maxillofac Surg. 2009 Apr; 38(4):321-5. Epub 2009 Feb 23. DOI: https://doi.org/10.1016/j.ijom.2009.01.006

Nathan RA, Eccles R, Howarth PH, Steinsví¥g SK, Togias A.Objective monitoring of nasal patency and nasal physiology in rhinitis. J Allergy Clin Immunol. 2005 Mar; 115(3 Suppl 1):S442-59. DOI: https://doi.org/10.1016/j.jaci.2004.12.015

Flemons W, Ward, Chair, American Association of Sleep Medicine Task Force (AASMTF) Sleep Related Breathing Disorders in Adults: Recommendations for Syndrome Definition and Measurement Techniques in Clinical Research. Sleep 22:5:667-689, 1999. 54 DOI: https://doi.org/10.1093/sleep/22.5.667

Ayappa I, Norman RG, Krieger AC, Rosen A, O'Malley RL, Rapoport DM. Non-Invasive Detection of Respiratory Effort-Related Arousals (RERAs) by a Nasal Cannula/Pressure Transducer System. Sleep 23:763-771, 2000. DOI: https://doi.org/10.1093/sleep/23.6.763

Ballester E, Badia JR, Hernandez L, Farre R, Navajas D, Montserrat JM. Nasal Prongs in the Detection of Sleep-Related Disordered Breathing in the Sleep Apneoea/Hypopnea Syndrome. European Respiratory Journal 11:1128-1134, 1998. DOI: https://doi.org/10.1183/09031936.98.11051128

Berg S, Haight JS, Yap V, Hoffstein V, Cole P. Comparison of Direct and Indirect Measurements of Respiratory Airflow: Implications for Hypopneas. Sleep 20:60-64, 1997. DOI: https://doi.org/10.1093/sleep/20.1.60

Clark SA, Wilson CR, Satoh M, Pegelow D, Dempsy JA. Assessment of Inspiratory Flow Limitation Invasively and Non-Invasively During Sleep. Am J Respir Crit Care Med 158:713-722, 1998. DOI: https://doi.org/10.1164/ajrccm.158.3.9708056

Epstein MD, Chicoine SA, Hanumara RC. Detection of Upper Airway Resistance Syndrome using a Nasal Cannula/Pressure Transducer. Chest 117:1073-1077, 2000. DOI: https://doi.org/10.1378/chest.117.4.1073

Guyatt, A.R., S.P. Parker, and M.J. McBride. 1982. Measurement of Human Nasal Ventilation Using an Oxygen Cannula as a Pitot Tube. Am Rev Respir Dis. 126:434-438, 1984. Hernandez L, Ballester E, Farre R, Badia JR, Lobelo R, Navajas D, Montserrat JM. Performance of Nasal Prongs in Sleep Studies. Chest 119:442-450, 2001. DOI: https://doi.org/10.1378/chest.119.2.442

Hosselet JJ, Norman RG Ayappa I, Rapoport DM. Detection of Flow Limitation with a Nasal Cannula Pressure Transducer System. AJRCCM 157:1461-1467, 1998. DOI: https://doi.org/10.1164/ajrccm.157.5.9708008

Hosselet J, Ayappa I, Norman RG, Krieger AC, Rapoport DM. Classification of Sleep-Disordered Breathing. Am J Respir Crit Care Med 163:398-405, 2001. DOI: https://doi.org/10.1164/ajrccm.163.2.9808132

Montserrat JM, Farre R, Ballester E, Felez MA, Pasto M, Navajas D. Evaluation of Nasal Prongs for Estimating Nasal Flow. Am J Respir Crit Care Med 155:211-215, 1997. DOI: https://doi.org/10.1164/ajrccm.155.1.9001314

Norman RG, Ahmed MM, Walsleben JA, Rapoport DM. Detection of Respiratory Events During NPSG : Nasal Cannula/Pressure Sensor Versus Thermistor. Sleep 20: 1175-1184, 1997.

Geurkink N. Nasal anatomy, physiology, and function.J Allergy Clin Immunol 1983; 72: 123–128. DOI: https://doi.org/10.1016/0091-6749(83)90518-3

Proctor DF. Nasal physiology and defence of the lungs. Am Rev Respir Dis 1977; 115: 97–129.

Ferris B, Mead J, Opie L. Partitioning of respiratory flow resistance in man. J Appl Physiol 1964; 19: 653–658. DOI: https://doi.org/10.1152/jappl.1964.19.4.653

Hasegawa M, Kern EB. Variations in nasal resistance in man: a rhinomanometric study of the nasal cycle in 50 human subjects. Rhinology 1978; 16: 19–29.

Eccles R. A role for the nasal cycle in respiratory defence. Eur Respir J 1996; 9: 371–376.

Widdicombe JG. The physiology of the nose. Clin Chest Med 1986; 7: 159–170. DOI: https://doi.org/10.1016/S0272-5231(21)00413-5

Duggan CJ, Watson RA, Pride NB. Postural changes in nasal and pulmonary resistance in subjects with asthma. J Asthma 2004; 41: 701–707. DOI: https://doi.org/10.1081/JAS-200027820

McNicholas W, Coffey M, Boyle T. Effects of nasal airflow on breathing during sleep in normal humans. Am Rev Respir Dis 1993; 147: 620–623. DOI: https://doi.org/10.1164/ajrccm/147.3.620

Douglas NJ, White DP, Weil JV, Zwillich CW. Effect Douglas NJ, White DP, Weil JV, Zwillich CW. Effect of breathing route on ventilation and ventilatory drive. Respir Physiol 1983; 51: 209–218. DOI: https://doi.org/10.1016/0034-5687(83)90041-5

Basner RC, Simon PM, Schwartzstein RM, Weinberger SE, Weiss JW. Breathing route influences upper airway muscle activity in awake normal adults. J Appl Physiol 1989; 66: 1766–1771. 55 DOI: https://doi.org/10.1152/jappl.1989.66.4.1766

Shi YX, Seto-Poon M, Wheatley JR. Breathing route dependence of upper airway muscle activity during hyperpnea. J Appl Physiol 1998; 84: 1701–1706. DOI: https://doi.org/10.1152/jappl.1998.84.5.1701

Coste A, Lofaso F, d'Ortho MP, et al. Protruding the tongue improves posterior rhinomanometry in obstructive sleep apnoea syndrome. Eur Respir J 1999; 14: 1278–1282. DOI: https://doi.org/10.1183/09031936.99.14612789

Ayappa I, Rapoport DM. The upper airway in sleep: physiology of the pharynx. Sleep Med Rev 2003; 7: 9–33. DOI: https://doi.org/10.1053/smrv.2002.0238

Park SS. Flow-regulatory function of upper airway in health and disease: a unified pathogenetic view of sleepdisordered breathing. Lung 1993; 171: 311–333. DOI: https://doi.org/10.1007/BF00165698

Fitzpatrick MF, McLean H, Urton AM, Tan A, O'Donnell D,Driver HS. Effect of nasal or oral breathing route on upper airway resistance during sleep. Eur Respir J 2003; 22:827–832. DOI: https://doi.org/10.1183/09031936.03.00047903

Fitzpatrick MF, Driver HS, Chatha N, Voduc N, Girard AM. Partitioning of inhaled ventilation between the nasal and oral routes during sleep in normal subjects.

J Appl Physiol 2003; 94: 883–890. DOI: https://doi.org/10.1152/japplphysiol.00658.2002

Hudgel DW. Variable site of airway narrowing among obstructive sleep apnea patients. J Appl Physiol 1986; 61: 1403–1409. DOI: https://doi.org/10.1152/jappl.1986.61.4.1403

Remmers JE, DeGroot WJ, Sauerland EK, Anch AM.Pathogenesis of upper airway occlusion during sleep. J Appl Physiol 1978; 44: 931–938 DOI: https://doi.org/10.1152/jappl.1978.44.6.931


Hilberg O, Jackson AC, Swift DL, et al. Acoustic rhinometry:Evaluation of nasal cavity geometry by acoustic reflection.J Appl Physiol 66:295–303, 1989.468 September–October 2006, Vol. 20, No. 5Property ofOceanSide PublicationsIP: DOI: https://doi.org/10.1152/jappl.1989.66.1.295

Holmstrom M, Scadding GK, Lund VJ, et al. Assessment of nasal obstruction. A comparison between rhinomanometry and nasal inspiratory peak flow. Rhinology 28:191–196, 1990.

Jones AS, Viani L, Phillips D, et al. The objective assessmentof nasal patency. Clin Otolaryngol 16:206–211, 1991. DOI: https://doi.org/10.1111/j.1365-2273.1991.tb01978.x

Dunagan D, and Georgitis J. Intranasal disease and provocation. In Diagnostic Testing of Allergic Disease, Vol. 15.

Hilberg O, Jensen FT, and Pedersen OF. Nasal airway geometry: Comparison between acoustic reflections and magnetic resonance scanning. J Appl Physiol 75:2811–2819, 1993. DOI: https://doi.org/10.1152/jappl.1993.75.6.2811

Corey JP, Gungor A, Nelson R, et al. A comparison of thenasal cross-sectional areas and volumes obtained withacoustic rhinometry and magnetic resonance imaging. Otolaryngol Head Neck Surg 117:349–354, 1997. DOI: https://doi.org/10.1016/S0194-5998(97)70125-6

Corey JP, Nalbone VP, and Ng BA. Anatomic correlates ofacoustic rhinometry as measured by rigid nasal endoscopy.Otolaryngol Head Neck Surg 121:572–576, 1999. DOI: https://doi.org/10.1016/S0194-5998(99)70058-6

Wihl JA, and Malm L. Rhinomanometry and nasal peakexpiratory and inspiratory flow rate. Ann Allergy 61:50–55,1998.

Min YG, and Jan YJ. Measurements of cross-sectional area ofthe nasal cavity by acoustic rhinometry and CT scanning.Laryngoscope 105:757–759, 1995. DOI: https://doi.org/10.1288/00005537-199507000-00014

Mamikoglu B, Houser S, Akbar I, et al. Acoustic rhinometryand computed tomography scans for the diagnosis of nasalseptal deviation, with clinical correlation. Otolaryngol HeadNeck Surg 123:61–68, 2000. DOI: https://doi.org/10.1067/mhn.2000.105255

Stewart MG, Witsell DL, Smith TL, et al. Development andvalidation of the nasal obstruction symptom evaluation(NOSE) scale. Otolaryngol Head Neck Surg 130:157–163,2004. DOI: https://doi.org/10.1016/j.otohns.2003.09.016

Numminen J, Dastidar P, and Rautiainen M. Influence ofsinus surgery in rhinometric measurements. J Otolaryngol33:98–103, 2004. DOI: https://doi.org/10.2310/7070.2004.02092

Velanovich V, Karmy-Jones R. Measuring gastroesophageal reflux disease: relationship between the health-relatedquality of life and physiologic parameters. Am Surg 64:649–653, 1998.

Wiklund I, Comerford MB, and Dimenas E. The relationshipbetween exercise tolerance and quality of life in anginapectoris. Clin Cardiol 14:204–208, 1991. DOI: https://doi.org/10.1002/clc.4960140306

Stewart MG, and Smith TL. Outcomes assessment in rhinology. Am J Rhinology 19:529–535, 2005. DOI: https://doi.org/10.1177/194589240501900518

Fairley JW, Durham LH, and Ell SR. Correlation of subjective sensation of nasal patency with nasal inspiratory peakflow rate. Clin Otolaryngol 18:19–22, 1993. DOI: https://doi.org/10.1111/j.1365-2273.1993.tb00803.x

Wang DY, Raza MT, Goh DYT, et al. Acoustic rhinometry innasal allergen challenge study: which dimensional measuresare meaningful? Clin Exp Allergy 34:1093–1098, 2004. DOI: https://doi.org/10.1111/j.1365-2222.2004.01988.x

Larsen K, and Kristensen S. Peak flow nasal patency indicesand self-assessment in septoplasty. Clin Otolaryngol 15:327–334, 1990. DOI: https://doi.org/10.1111/j.1365-2273.1990.tb00477.x

Roithmann R, Cole P, Chapnik J, et al. Acoustic rhinometry,rhinomanometry, and the sensation of nasal patency: a correlative study. J Otolaryngol 23:454–458, 1994.

Hilberg O, and Pedersen OF. Acoustic rhinometry: Recommendations for technical specifications and standard operating procedures. Rhinol Suppl 16:3–17, 2000. 73

Fisher EW, Morris DP, Biemans JM, et al. Practical aspects ofacoustic rhinometry: Problems and solutions. Rhinology 33:219–223, 1995.

Parvez L, Erasala G, and Noronha A. Novel techniques,standardization tools to enhance reliability of acoustic rhinometry measurements. Rhinol Suppl 16:18–28, 2000.

Wilson AM, Fowler SJ, Martin SW, et al. Evaluation of the importance of head and probe stabilisation in acoustic rhinometry. Rhinology 39:93–97, 2001.

Tomkinson A, and Eccles R. Acoustic rhinometry: Do weneed a standardized operating procedure? Clin Otolaryngol21:284–287, 1996. DOI: https://doi.org/10.1111/j.1365-2273.1996.tb01743.x

Cho SI, Hauser R, and Christiani DC. Reproducibility ofnasal peak inspiratory flow among healthy adults. Chest112:1547–1553, 1997. DOI: https://doi.org/10.1378/chest.112.6.1547

Starling-Schwanz R, Peake HL, Salome CM, et al. Repeatability of peak nasal inspiratory flow measurements andutility for assessing the severity of rhinitis. Allergy 60:795–800, 2005. DOI: https://doi.org/10.1111/j.1398-9995.2005.00779.x

Frolund L, Madsen F, Mygind N, et al. Comparison betweendifferent techniques for measuring nasal patency in a groupof unselected patients. Acta Otolaryngol 104:175–179, 1987. DOI: https://doi.org/10.3109/00016488709109064

Corey JP, Gungor A, Nelson R, et al. Normative standardsfor nasal cross-sectional areas by race as measured by acoustic rhinometry. Otolaryngol Head Neck Surg 199:389–393,1998. DOI: https://doi.org/10.1016/S0194-5998(98)70085-3

Millqvist E, and Bende M. Reference values for acousticrhinometry in subjects without nasal symptoms. Am J Rhinol 12:341–343, 1998. DOI: https://doi.org/10.2500/105065898780182462

Ozturk F, Turktas I, Asal K, et al. Effect of intranasal triamcinolone acetonide on bronchial hyper-responsiveness inchildren with seasonal allergic rhinitis and comparison ofperceptional nasal obstruction with acoustic rhinometric assessment. Int J Pediatr Otorhinolaryngol 68:1007–1015, 2004. DOI: https://doi.org/10.1016/j.ijporl.2004.03.006

Panagou P, Loukides S, Tsipra S, Syrigou K, Anastasakis C, Kalogeropoulos N. Evaluation of nasal patency: comparison of patient and clinician assessments with rhinomanometry. Acta Otolaryngol. 1998 Nov; 118(6):847-51. DOI: https://doi.org/10.1080/00016489850182567

Simola M, Malmberg H.Sensation of nasal airflow compared with nasal airway resistance in patients with rhinitis.Clin Otolaryngol Allied Sci. 1997 Jun; 22(3):260-2.

Correlation between objective and subjective assessments of nasal patency. ORL J Otorhinolaryngol Relat Spec. 1998 Jul-Aug ;60(4):206-11. DOI: https://doi.org/10.1159/000027595

Gordon A.S., McCaffrey T.V., Kern E.B. et al. (1989) Rhinomanometry for preoperative and postoperative assessment of nasal obstruction. Otolaryngol. Head Neck Surg. 101, 20–26 DOI: https://doi.org/10.1177/019459988910100105

Jones A.S., Willatt D.J. & Durham L.M. (1989) Nasal airflow: resistance and sensation. J. Laryngol. Otol. 103, 909–911 DOI: https://doi.org/10.1017/S0022215100110485

Grymer L.F., Hilberg O., Elbrí¸nd O. et al. (1989) Acoustic rhinometry: evaluation of the nasal cavity with septal deviations, before and after septoplasty. Laryngoscope 99, 1180–1187 DOI: https://doi.org/10.1288/00005537-198911000-00015

Sipila¨ J., Suonpa¨a¨ J. & Laippala P. (1994) Sensation of nasal obstruction compared to rhinomanometric results in patients referred for septoplasty. Rhinology 32, 141–144

Marais J., Murray J.A., Marshall I. et al. (1994) Minimal crosssectional areas, nasal peak flow and patients' satisfaction in septoplasty and inferior turbinectomy. Rhinology 32, 145–147

Simola M. & Malmberg H. (1997) Sensation of nasal airflow compared with nasal airway resistance in patients with rhinitis.Clin. Otolaryngol. 22, 260–262 DOI: https://doi.org/10.1046/j.1365-2273.1997.00033.x

Shemen L. & Hamburg R. (1997) Preoperative and postoperative nasal septal surgery assessment with acoustic rhinometry. Otolaryngol. Head Neck Surg. 117, 338–342 74 DOI: https://doi.org/10.1016/S0194-5998(97)70123-2

Szucks E. & Clement P.A. (1998) Acoustic rhinometry and rhinomanometry in the evaluation of nasal patency of patients with nasal septal deviation. Am. J. Rhinol. 12, 345–352 DOI: https://doi.org/10.2500/105065898780182507

Reber M., Rahm F. & Monnier P. (1998) The role of acoustic rhinometry in the pre- and postoperative evaluation of surgery for nasal obstruction. Rhinology 36, 184–187

Gungor A., Moinuddin R., Nelson R.H. et al. (1999) Detection of the nasal cycle with acoustic rhinometry: techniques and applications. Otolaryngol. Head Neck Surg. 120, 238–247 DOI: https://doi.org/10.1016/S0194-5998(99)70413-4

Naito K., Miyata S., Saito S. et al. (2001) Comparison of perceptional nasal obstruction with rhinomanometric and acoustic rhinometric assessment. Eur. Arch. Otorhinolaryngol. 258, 505–508 DOI: https://doi.org/10.1007/s004050100360

Numminen J., Ahtinen M., Huhtala H. et al. (2003) Comparison of rhinometric measurements methods in intranasal pathology. Rhinology 41, 65–68

Suzina A.H., Hamzah M. & Samsudin A.R. (2003) Objective assessment of nasal resistance in patients with nasal disease. J. Laryngol. Otol. 117, 609–613 DOI: https://doi.org/10.1258/002221503768199933

Clarke J.D., Hopkins M.L. & Eccles R. (2005) Evidence for correlation of objective and subjective measures of nasal airflow in patients with common cold. Clin. Otolaryngol. 30, 35–38 DOI: https://doi.org/10.1111/j.1365-2273.2004.00915.x

Clarke J.D., Hopkins M.L. & Eccles R. (2006) How good are patients at determining which side of the nose is more obstructed? A study on the limits of discrimination of the subjective assessment of unilateral nasal obstruction. Am. J. Rhinol. 20, 20–24 DOI: https://doi.org/10.1177/194589240602000104


Daniel RK. Rhinoplasty: An Atlas of Surgical Techniques. New York: Springer-Verlag; 2002. p.183-96.

Sciuto S, Bernardeschi D. Excision and replacement of nasal septum in aesthetic and functional nose surgery: setting criteria and establishing indications. Rhinology 1999;37:74-9.

Gomulinski L. Morphological aspect of septal deformations. Their correction during complex rhinopalsties. Ann Chir Plast 1982;27: 343-9.

Mladina R. The role of maxillary morphology in the development of pathological septal deviations. Rhinology 1987; 25:199-205.

Guyuron B, Uzzo CD, Scull H. A practical classification of septonasal deviation and an effective guide to septal surgery. Plast Reconstr Surg 1999;104:2202-9. DOI: https://doi.org/10.1097/00006534-199912000-00041

Edwards N. Septoplasty: Rational surgery of the nasal septum. J Laryngol Otol 1974;88:875-97. DOI: https://doi.org/10.1017/S0022215100081172

Buyukertan M, Keklikoglu N, Kokten G. A morphometric consideration of nasal septal deviations by people with paranasal complaints; a computed tomography study. Rhinology 2003;41: 21-4.

Podoshin L, Gertner R, Fradis M, Berger A. Incidence and treatment of deviation of nasal septum in newborns. Ear Nose Throat J 1991;70:485-7.

Dinis PB, Haider H. Septoplasty: long-term evaluation of results. Am J Otolaryngol 2002;23:85-90. DOI: https://doi.org/10.1053/ajot.2002.30987

Sciuto S, Bernardeschi D. Excision and replacement of nasal septum in aesthetic and functional nose surgery: setting criteria and establishing indications. Rhinology 1999;37:74-9.

Baumann I. A new classification of septal deviations: Rhinology;45:2007. p.200-223

Lawson W, Reino AJ. Correcting functional problems. Facial Plast Surg Clin North Am 1994;2:501-20.

Jugo SB. Surgical Atlas of External Rhinoplasty. Edinburg: Churchill-Livingston;1995. p.60-

Boccieri A, Pascali M. Septal crossbar graft for the correction of the crooked nose. Plast Reconstr Surg. 2003;111(2):629-638. DOI: https://doi.org/10.1097/01.PRS.0000042205.27330.E4

Patterson CN. Surgery of the crooked nose. Laryngoscope. 1981;91(6):939-944. DOI: https://doi.org/10.1288/00005537-198106000-00011

Ellis DA, Gilbert RW. Analysis and correction of the crooked nose. J Otolaryngol.1991;20(1):14-18.

Rohrich RJ, Gunter JP, Deuber MA, Adams WP Jr. The deviated nose: optimizing results using a simplified classification and algorithmic approach. Plast Reconstr Surg. 2002;110 (6):1509-1523. DOI: https://doi.org/10.1097/00006534-200211000-00018

Sciuto S, Bernardeschi D. Excision and replacement of nasal septum in aesthetic and functional nose surgery: setting criteria and establishing indications. Rhinology 1999;37:74-9.

Mladina R. Correction of nasal septal deformities. Rhinology 1994;20:146-152.

Bejar I, Farkas LG, Messner AH, and Crysdale WS. 1996. "Nasal growth after external septoplasty in children." Arch Otolaryngol Head Neck Surg. 122: 816-821. DOI: https://doi.org/10.1001/archotol.1996.01890200008002

Carlson BM. 1998. "Development of head and nect." In: Human Embryology and Developmental Biology. St. Louis: Mosby. pp 283-286. 95

Carlson DS. 2005. "Theories of Craniofacial Growth in the Postgenomic Era." Seminars in Orthodontics. 11(4, December): 172-183. DOI: https://doi.org/10.1053/j.sodo.2005.07.002

Cole P, Chaban R, Naito K, and Oprysk D. 1988. "The obstructive nasal septum: effect of simulated deviations on nasal airflow resistance." Arch Otolaryngol Head Neck Surg. 114: 410-412. DOI: https://doi.org/10.1001/archotol.1988.01860160054020

Copray JC. 1986. "Growth of the nasal septal cartilage of the rat in vitro." Journal of Anatomy. 144: 99-111.

Cupero TM, Middleton CE, and Silva AB. 2001. "Effects of functional septoplasty on the facial growth of ferrets." Arch Otolaryngol Head Neck Surg. 127(11, November): 1367-1369. DOI: https://doi.org/10.1001/archotol.127.11.1367

D'Ascanio L, Lancione C, Pompa G, Rebuffini E, Mansi N, and Manzini M. 2010. "Craniofacial growth in children with nasal septum deviation: a cephalometric comparative study." International Journal of Pediatric Otorhinolaryngology. 74(10, October): 1180-1183. DOI: https://doi.org/10.1016/j.ijporl.2010.07.010

Figueroa A, Holton N, Yokley T, and Southard T. 2011. Abstract: "Septal deviation and facial form in a European derived population." 89th Annual IADR/AADR General Session and Exhibition. San Diego, CA.

Fitz, CR. 1983. "Holoprosencephaly and related entities." Neuroradiology. 25: 225-238. DOI: https://doi.org/10.1007/BF00540235

Freng A. 1981. "Mid-facial growth following resection of the nasal septum-vomer: a roentgencephalometric study in the domestic cat." Acta Otolaryngology. 92: 363-370. DOI: https://doi.org/10.3109/00016488109133273

Freng A, Kvam E, and Kramer J. 1988. "Facial skeletal dimensions in patients with nasal septal deviation." Scandinavian Journal of Plastic and Reconstructive Surgery. 22(1, January): 77-81. 71 DOI: https://doi.org/10.3109/02844318809097938

Friede H. 1978. "The Vomero-Premaxillary Suture: a neglected growth site in mid-facial development of unilateral cleft lip and palate patients." Cleft Palate J. 15: 398–404.

Friede H, and Morgan P. 1976. "Growth of the vomero-premaxillary suture in children with bilateral cleft lip and palate. A histological and roentgencephalometric study."Scandinavian Jjournal of Plastic and Reconstructive Surgery. 10(1, January): 45-55. DOI: https://doi.org/10.1080/02844317609169745

Genecov JS, Sinclair PM, and Dechow PC. 1990. "Development of the nose and soft tissue profile." The Angle Orthodontist. 60(3): 191-198.

Gray LP. 1978. "Deviated nasal septum: incidence and etiology." Ann Oto Rhinol Laryngol Suppl. 87(3, Suppl 50): 3-20. DOI: https://doi.org/10.1177/00034894780873S201

Gray LP. 1983. "The development and significance of septal and dental deformity from birth to eight years." Int J Pediatr Otorhinolaryngol. 6(3, Dec): 265-277. DOI: https://doi.org/10.1016/S0165-5876(83)80128-1

Hafezi F, Naghibzadeh B, Nouhi AH, and Yavari P. 2010. "Asymmetric facial growth and deviated nose: a new concept." Annals of Plastic Surgery. 64(1, January): 47-51. DOI: https://doi.org/10.1097/SAP.0b013e31819ae02d

Hans MG, Scaletta L, and Occhino JC. 1996. "The effects of antirat nasal septum cartilage antisera on facial growth in the rat." American Journal of Orthodontics and Dentofacial Orthopedics. 109(6, June): 607-615. DOI: https://doi.org/10.1016/S0889-5406(96)70072-0

Harari D, Redlich M, Miri S, Hamud T, and Gross M. 2010. "The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients." The Laryngoscope. 120(10, October): 2089-2093. DOI: https://doi.org/10.1002/lary.20991

Harvold EP, Vargervik K, and Chierici G. 1973. "Primate experiments on oral sensation and dental malocclusions." American journal of orthodontics. 63(5, May): 494-508. 96 DOI: https://doi.org/10.1016/0002-9416(73)90162-0

Vig K . 1998. "Nasal obstruction and facial growth: the strength of evidence for clinical assumptions." American Journal of Orthodontics and Dentofacial Orthopedics. 113(6, June): 603-611. DOI: https://doi.org/10.1016/S0889-5406(98)70219-7

Wada T, Kremenak CR, and Miyazaki T. 1980. "Midfacial growth effects of surgical trauma to the area of the vomer in beagles." The Journal of Osaka University Dental School. 20: 241-276.

Wealthall RJ, and Herring SW. 2006. "Endochondral ossification of the mouse nasal septum." Anat Rec A Discov Mol Cell Evol Biol. 288(11, November): 1163-1172. Hinrichsen KV. 1985. DOI: https://doi.org/10.1002/ar.a.20385

Kawalski H and Spiewak P. 1998. "How septum deformations in newborns occur." International Journal of Pediatric Otorhinolaryngolog.y 44(1, June): 23-30. DOI: https://doi.org/10.1016/S0165-5876(98)00036-6

Kemble JV. 1973. "The importance of the nasal septum in facial development." The Journal of Laryngology and Otology. 87(4, April): 379-86. DOI: https://doi.org/10.1017/S0022215100077021

Kim J, Kim SW, Kim SW, Cho JH, and Park YJ. 2012. "Role of the Sphenoidal Process of the Septal Cartilage in the Development of Septal Deviation." Otolaryngol Head Neck Surg. 146(1): 151-155. DOI: https://doi.org/10.1177/0194599811425000

Kimes K, Mooney M, Siegel M, and Todhunter J. 1992. "Growth rate of the vomer in normal and celft lip and palate human fetal specimens." Cleft Palate Craniofac J. 29(1): 38-43. DOI: https://doi.org/10.1597/1545-1569(1992)029<0038:GROTVI>2.3.CO;2

Meredith HV. 1959. "A longitudinal study of growth in face depth during childhood."American Journal of Physical Anthropology. 17(2): 125-135 DOI: https://doi.org/10.1002/ajpa.1330170208

Mladina R, Cujií¦ , Subarií¦ M, and Vukovií¦ K. 2008. "Nasal septal deformities in ear, nose, and throat patients: an international study." American Journal of Otolaryngology. 29(2): 75-82 DOI: https://doi.org/10.1016/j.amjoto.2007.02.002


Bauman I, Bauman H. A new classification of septal deviations. Rhinology 2007, vol.45:220-223

Becker OJ: Rhinoplasty: cultural, esthetic and psychological aspects. Chicago Med 1996: 64:230-235

Bosma JF: Anatomy of the Infant Head. Johns Hopkins University Press, 1986 Clement PAR. Committee raport on standardization of rhinometry. 2000; Rhinology 22: 151-155

Cottle MH, Loring RM, Fisher GC: the maxilla premaxilla approach to extensive nasal septum surgery. Arch Otolaryngol 1958: 68:303 DOI: https://doi.org/10.1001/archotol.1958.00730020311003

Deron Bj, Clement PA, Derde MP. The influence of septal surgery on tubal function. Acta otorhinolaryngol Belg 2003;45: 311-3

Eccles R. A role for the nasal cycle in respiratory defence. Eur Respiratory J 1996; 9:371-376 Gaskins RE Jr. A surgical staging system for chronic Rhinosinusitis. Am J Rhinolo 2004;6:15 DOI: https://doi.org/10.1183/09031936.96.09020371

Goin, J.M., and Goin, M. K. Chainging the Body: Psychological Effects Of Plastic Surgery. Baltimore: Williams&Wilkins, 2001

Gorney M: In: Rees TD (ed): Rhinoplasty: Problems and controversies. The septum in rhinoplasty. St. Louis: C. V. Mosby, 1988, p 269

Gorney, M. Psychiatric and medical-legal implications of rhinoplasty, mentoplasty, and otoplasty. Symposium of Aesthetic Surgery of the Nose, Ears and Chin. Vol. 6. St. Louis: Mosby, 1973

Grymer LF, Hilberg o, Pedersen OF, Rasmussen TR. Acoustic rhinometry: values from adults with subjective normal nasal patency. 1991; Rhinology 29;35-47

Gunter JP, Rohrich RJ: Management of the deviated nose. The importance of septal reconstruction. Clin Plast Surg 1988;15;43 DOI: https://doi.org/10.1016/S0094-1298(20)31464-4

Guyuron B, Uzzo CD, Scull H. A practical classification of septonasal deviation and an effective guide to septal surgery. Plast reconstr Surg 1999; 104:22-2-28 DOI: https://doi.org/10.1097/00006534-199912000-00042

Hilberg O. Objective measurement of nasal airway dimensions using acoustic rhinometry: methodological and clinical aspects. Allergy Suppl 2002; 70; 57: 5-39 DOI: https://doi.org/10.1046/j.0908-665x.2001.all.doc.x

Huizing E. Implantation and transplantation in reconstructive nasal surgery. Rhinology 1974;12:93-106

Huizing E, Mackay I, Rettinger G. reconstruction of the nasal septum and dorsum by cartilage transplants-autogenic or allogenic?Rhinology 1989;27:5-10

Huizing E, de Groot JAM. Functional reconstructive nasal surgery. Thieme, Stuttgart New York, 2003 DOI: https://doi.org/10.1055/b-0034-40789

Jacobson, W. E., et al. Psychiatric evaluation of male patients seekin cosmetic surgery. Plast. Reconstr. Surg. 26:356, 1950 DOI: https://doi.org/10.1097/00006534-196010000-00003

Jeppesen F: Septo-and Rhinoplasty: a Step-by step Instruction. Copenhagen: Munksgaard 1986

Killian G: The submucous window resection of the nasal septum. Ann Otol Rhinol Laryngol. 1905;14:363 DOI: https://doi.org/10.1177/000348940501400210

Lemmens W, Lemkens P. Septal suturing following nasal septoplasty, a valid alternative for nasal packing? Acta Otorhinolaryngol Belg 2001;55:215-221

Mladina R, Djanic D, Milicic D. Histological Changes of the middle turbinate mucosa in otorinologia. 1996: 151-5

Mladina R. The role of maxillar morphology in the development of pathological septal deformities. Rhinology 1987;27: 113-118

Mladina R., Krajina Z. The influence of the caudal process on the formation of septal deformities. Rhinology 1999;27;113-118 133

Mlynsky G. Surgery of the Nasal Septum. Facial Plastic Syrgery. 2006; Vol.22, 223-229 DOI: https://doi.org/10.1055/s-2006-954840

Mlynsky G. Wiederherstellende Verfahren bei gestorter Funktion der oberen Atemwege. Nasale Atmung. Laryngo-rhinootologie 2005;84:101-117 DOI: https://doi.org/10.1055/s-2005-861133

Mlynski G. Physiology and Pathophysiology of nasal breathing. In: Behrbohm H, Tardy ME, eds. Essentials of septorhinoplasty. New York, NY; Thieme;2004

Murakami W, Wong L, Davison J; Application of the biomedical behaviour of cartilage to nasal septoplastic surgery. Laryngoscope 1999; 92:300 DOI: https://doi.org/10.1288/00005537-198203000-00015

Palmer, A., and Blanton, S. Mental factors in relation to reconstructive surgery of nose and ears. Arch. Otolaryng. Haed and Neck Surg. 56:148, 1952 DOI: https://doi.org/10.1001/archotol.1952.00710020167006

Perkins SW: Anatomy and Physiology. In: Krause ChJ: Aesthetic facial surgery. Philadelphia: Lippincott Company 2003

Pirsig W, Kern EB, Verse T. Reconstruction of anterior nasal septum: back-to-back autogenous ear cartilage graft. Laryngoscope 2004; 114:627-638 DOI: https://doi.org/10.1097/00005537-200404000-00007

Rettinger G. Aktuelle Aspekte der Septorinoplastik. Otorhinolaryngol Nova 2005;84:2-42 Samad I, Stevens HE, Maloney A. The Effiacy of nasal septal syrgery. J Otolaryngol

(Canada) 1992;21:88-91 DOI: https://doi.org/10.1016/S0196-0644(05)82248-6

Seltzer A. The nasal septum: plastic repair of the deviated septum associated with deflected tip. Arch. Otolaryngol 1996;40:433-444 DOI: https://doi.org/10.1001/archotol.1944.00680020563001

Stern, K., Fournier, G., and LaRiviere, A. Psychiatric aspects of cosmetic surgery of the nose. Can. Med. Assoc. 76:469, 1957

Tadzic A, Gilbert SE, Sade J: Complications of submucous resection of the nasal septum. Arch Otorhinolaryngol 245(2):74, 1988 DOI: https://doi.org/10.1007/BF00481439

Tomkinson A. Eccles R. Comparation of the relative abilities of acoustic rhinometry, rhinomanometry, and the visual analogue scale in detecting change in the nasal cavity in a healthy adult population. Am J rhinol 2002; 10:161-165 DOI: https://doi.org/10.2500/105065896781794923

Vilar-Sancho B: Rhinoseptoplasty. Aesth Plast Surg 1984;8:61 Willemot J. Anatomie et Traumatisme du nez. Septorhinoplastie. Nez et estetique. Acta Otorhinolaryngol. Bel 1992; 35 (Suppl II): 201-350 DOI: https://doi.org/10.1007/BF01575246

Lawson W, Kessler S, Biller HF: Unusual and Fatal Complications of Rhinoplasty. Arch Otolaryngol 1983;109:164-169 DOI: https://doi.org/10.1001/archotol.1983.00800170030008

Tamerin JA: Management of hemorrhage post rhinoplasty. NY State J Med 1967;67:550-555 38.

Tardy ME Jr et al: Micro-osteotomy in Rhinoplasty. Facial Plast Surg 1984;1: 137-145Nolst DOI: https://doi.org/10.1055/s-0028-1085244

Trenité GJ: Surgery of the osseocartilaginous vault. In: Rhinoplasty.A practical guide to functional and aesthetic surgery of the nose. 3rd edition. Kugler Publications, The Hague, The Netherlands, 2005; Chapter 11:97-115

Rettinger G, Steininger H: Lipogranulomas as Complications of Septorhinoplasty. Arch Otolaryngol Head Neck Surg 1997; 123:809-814 DOI: https://doi.org/10.1001/archotol.1997.01900080041003

Rettinger G, Kirsche H: Complications in septoplasty. Facial Plast Surg 2006; 22: 289-297 DOI: https://doi.org/10.1055/s-2006-954847

Tardy ME Jr, Kron TK, Younger R, Key M: The Cartilaginous Pollybeak: Etiology, Prevention, and Treatment. Facial Plast Surg 1989; 6: 113-120 DOI: https://doi.org/10.1055/s-2008-1064718

Murakami CS, Larrabee WF Jr: Comparison of Osteotomy Techniques in the Treatment of Nasal Fractures.Facial Plast Surg 1992; 8: 209-219 DOI: https://doi.org/10.1055/s-2008-1064652

Sheen JH: Spreader Graft: A Method of Reconstructing the Roof of the Middle Nasal Vault Following Rhinoplasty. Plastic and Reconstructive Surgery; 1984: 73: 230-239 134 DOI: https://doi.org/10.1097/00006534-198402000-00013

Toriumi DM, Josen J, Weinberger M, Tardy ME Jr.: Use of Alar Batten Grafts for Correction of Nasal Valve Collapse. Arch Otolarnygol Head Neck Surg 1997; 123: 802-808 DOI: https://doi.org/10.1001/archotol.1997.01900080034002

Menger DJ: Lateral Crus Pull-up. Arch Facial Plast Surg 2006; 8: 333-337 DOI: https://doi.org/10.1001/archfaci.8.5.333

McCollough EG, Mangat D: Systematic Approach to Correction of the Nasal Tip in Rhinoplasty. Arch Otolaryngol 1981; 107: 12-6 DOI: https://doi.org/10.1001/archotol.1981.00790370014002

Adamson PA, Litner JA: Applications of the M-arch Model in Nasal Tip Refinement. Facial Plast Surg 2006; 22: 42-48 DOI: https://doi.org/10.1055/s-2006-939951

Adamson PA, Funk E: Nasal tip dynamics. Facial Plast Surg Clin North Am. 2009; 17: 29-49 DOI: https://doi.org/10.1016/j.fsc.2008.09.008

Kridel RW, Scott BA, Foda HM: The Tongue-in-Groove Technique in Septorhinoplasty. Arch Facial Plast Surg 1999; 1: 246-58 DOI: https://doi.org/10.1001/archfaci.1.4.246

Byrd HS, Andochick S, Copit S, Walton KG: Septal Extension Grafts: A Method of Controlling Tip Projection Shape. Plast Reconstr Surg 1997; 100: 999-1010 DOI: https://doi.org/10.1097/00006534-199709001-00026


Hens G, Picavet VA, Poorten VV, Schoenaers J, Jorissen M, Hellings PW: High patient satisfaction after secondary rhinoplasty Int Forum Allergy Rhinol. 2011 May-Jun; 1(3):167-72 DOI: https://doi.org/10.1002/alr.20023

Wright MR, Wright WK: A psychological study of patients undergoing cosmetic surgery. Arch Otorolaryngol 1975;101:145-151 DOI: https://doi.org/10.1001/archotol.1975.00780320003001

Pecorari G, Gramaglia C, Garzaro M, Abbate-Daga G, Cavallo GP, Giordano C, Fassino S: Self-esteem and personality in subjects with and without body dysmorphic disorder traits undergoing cosmetic rhinoplasty: preliminary data; J Plast Reconstr Aesthet Surg. 2010 Mar;63(3):493-8. Epub 2008 Dec 30 DOI: https://doi.org/10.1016/j.bjps.2008.11.070

Goin MK, Burgoyne RW, Goin JM, Staples FR: A prospective psychological study of 50 female face-lift patients. Plast Reconstr surg 1980; 65:436-442 DOI: https://doi.org/10.1097/00006534-198004000-00007

Psychopathology symptoms in a sample of female cosmetic surgery patients. Journal of Plastic, Reconstructive & Aesthetic Surgery, Volume 65, Issue 3, March 2012, Pages 321.327 DOI: https://doi.org/10.1016/j.bjps.2011.09.038

Gorney M. Psychiatric and-medical legal implications of rhinoplasty, mentoplasty and otoplasty. Symposium of aesthetic surgery of the Nose, ears and chin. Vol.6, St. Louis; Mosby, 1995

The Dangerous Dozen, Avoiding Potential Problem Patients in Cosmetic Surgery; Facial Plastic Surgery Clinics of North America, Volume 16, Issue 2, May 2008, Pages 195. 202 DOI: https://doi.org/10.1016/j.fsc.2007.11.010

Sarwer DB.High prevalence of body dysmorphic disorder symptoms in patients seeking rhinoplasty. Plast Reconstr Surg. 2011 Aug; 128(2):518-9.

David C. W, The Changing Definition of Beauty; Facial Plastic Surgery. 22:198-203:2006 DOI: https://doi.org/10.1055/s-2006-950178

Goin MK, Rees TD: A prospective study of patientfs psychological reactions to rhinoplasty. Ann Plast Surg 1991; 27:210-215 DOI: https://doi.org/10.1097/00000637-199109000-00004

Davis R. Doctors will transplant a face-but whose; USA Today. May 24, 2006

Og.odek E, Mo. D, Marek L, Placek W.Pol Maybe the way to beauty is compulsion; Merkur Lekarski. 2009 Dec; 27(162):529-31

Sarwer DB: Discussion: High prevalence of body dysmorphic disorder symptoms in patients seeking rhinoplasty; Plast Reconstr Surg. 2011 Aug; 128(2):518-9. DOI: https://doi.org/10.1097/PRS.0b013e31821e7248

Picavet VA, Prokopakis EP, Gabriels L, Jorissen M, Hellings PW. High prevalence of body dysmorphic disorder symptoms in patients seeking rhinoplasty; Plast Reconstr Surg. 2011 DOI: https://doi.org/10.1097/PRS.0b013e31821b631f

Phillips KA, Grant J, Siniscalchi J, Albertini RS; Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder; Psychosomatics. 2001 Nov-Dec; 42(6):504-10.

Picavet V, Gabriels L, Jorissen M, Hellings Screening tools for body dysmorphic disorder in a cosmetic surgery setting; PW.Laryngoscope. 2011 Dec; 121(12):2535-41. DOI: https://doi.org/10.1002/lary.21728

Yu K, Kim A, Pearlman SJ: Functional and aesthetic concerns of patients seeking revision rhinoplasty;.Arch Facial Plast Surg. 2010 Sep-Oct; 12(5):291-7. DOI: https://doi.org/10.1001/archfaci.2010.62

Og.odek E, Mo. D, Marek L, Araszkiewicz A, Placek W.Pol Merkur Maybe the way to beauty is compulsion?]. Lekarski. 2009 Dec; 27(162):529-31

Alavi M, Kalafi Y, Dehbozorgi GR, Javadpour A.Body dysmorphic disorder and other psychiatric morbidity in aesthetic rhinoplasty candidates. J Plast Reconstr Aesthet Surg. 2011 Jun; 64(6):738-41. Epub 2011 Jan 26. 157 DOI: https://doi.org/10.1016/j.bjps.2010.09.019

Andretto Amodeo C. The central role of the nose in the face and the psyche: review of the nose and the psyche. Aesthetic Plast Surg. 2007 Jul-Aug; 31(4):406-10. DOI: https://doi.org/10.1007/s00266-006-0241-2

Thomas JR, Sclafani AP, Hamilton M, McDonough E. Preoperative identification of psychiatric illness in aesthetic facial surgery patients. Aesthetic Plast Surg 2001;25:64-67. DOI: https://doi.org/10.1007/s002660010097

Ishigooka J, Iwao M, Suzuki M, Fukuyama Y, Murasaki M, Miura S. Demographic features of patients seeking cosmetic surgery. Psychiatry Clin Neurosci 1998;52:283-287. DOI: https://doi.org/10.1046/j.1440-1819.1998.00388.x

Ritvo EC, Melnick I, Marcus GR, Glick ID. Psychiatric conditions in cosmetic surgery patients. Facial Plast Surg 2006;22:194-197. DOI: https://doi.org/10.1055/s-2006-950177

Sarwer DB, Crerand CE. Psychological issues in patient outcomes. Facial Plast Surg 2002;18:125-133. DOI: https://doi.org/10.1055/s-2002-32203

Pavan C, Simonato P, Marini M, Mazzoleni F, Pavan L, Vindigni V. Psychopathologic aspects of body dysmorphic disorder: a literature review. Aesthetic Plast Surg 2008;32:473-484. DOI: https://doi.org/10.1007/s00266-008-9113-2

Bolton MA, Pruzinsky T, Cash TF, Persing JA. Measuring outcomes in plastic surgery: body image and quality of life in abdominoplasty patients. Plast Reconstr Surg 2003;112:619-625. DOI: https://doi.org/10.1097/01.PRS.0000070972.57000.08

Cash TF, Duel LA, Perkins LL. Women's psychosocial outcomes of breast augmentation with silicone gel-filled implants: a 2-year prospective study. Plast Reconstr Surg 2002;109:2112-2121. DOI: https://doi.org/10.1097/00006534-200205000-00049

Sarwer DB, Gibbons LM, Magee L, Baker JL, Casas LA, Glat PM, et al. A prospective, multi-site investigation of patient satisfaction and psychosocial status following cosmetic surgery. Aesthet Surg J 2005;25:263-269. DOI: https://doi.org/10.1016/j.asj.2005.03.009

Sarwer DB, Wadden TA, Whitaker LA. An investigation of changes in body image following cosmetic surgery. Plast Reconstr Surg 2002;109:363-369. DOI: https://doi.org/10.1097/00006534-200201000-00060

Jakubietz M, Jakubietz RJ, Kloss DF, Gruenert JJ. Body dysmorphic disorder: diagnosis and approach. Plast Reconstr Surg 2007;119:1924-1930. DOI: https://doi.org/10.1097/01.prs.0000259205.01300.8b

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Ed, Text Revision. Washington, D.C.: American Psychiatric Association, 1994.

Sarwer DB, Pertschuk MJ, Wadden TA, Whitaker LA. Psychological investigations in cosmetic surgery: a look back and a look ahead. Plast Reconstr Surg 1998;101:1136-1142.

Buhlmann U, Marques LM, Wilhelm S. Traumatic experiences in individuals with body dysmorphic disorder. J Nerv Ment Dis 2012;200:95-98. DOI: https://doi.org/10.1097/NMD.0b013e31823f6775

Phillips KA, Pinto A, Jain S. Self-esteem in body dysmorphic disorder: Body Image. Int J Res 2004;1:385.390. DOI: https://doi.org/10.1016/j.bodyim.2004.07.001

World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders. Clinical descriptions and diagnostic guidelines. Available via: http://www.who.int/classifications/icd/en/bluebook.pdf (Accessed at: April 10, 2012).

Phillips KA, Dufresne RG. Body dysmorphic disorder. A guide for dermatologists and cosmetic surgeons. Am J Clin Dermatol 2000;1:235-243. DOI: https://doi.org/10.2165/00128071-200001040-00005

Phillips KA, Grant J, Siniscalchi J, Albertini RS. Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics 2001;42:504-510. DOI: https://doi.org/10.1176/appi.psy.42.6.504

Sarwer DB, Pertschuk MJ, Wadden TA, Whitaker LA. Psychological investigations in cosmetic surgery: a look back and a look ahead. Plast Reconstr Surg 1998;101:1136-1142. DOI: https://doi.org/10.1097/00006534-199804040-00040

Sarwer DB, Crerand CE, Didie ER. Body dysmorphic disorder in cosmetic surgery patients. Facial Plast Surg 2003;19:7-18. 158 DOI: https://doi.org/10.1055/s-2003-39137

Honigman RJ, Phillips KA, Castle DJ. A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg 2004;113:1229-1237. DOI: https://doi.org/10.1097/01.PRS.0000110214.88868.CA

Sarwer DB. Awareness and identification of body dysmorphic disorder by aesthetic surgeons: results of a survey of american society for aesthetic plastic surgery members. Aesthet Surg J 2002;22:531-535. DOI: https://doi.org/10.1067/maj.2002.129451

Gorney M. Recognition and management of the patient unsuitable for aesthetic surgery. Plast Reconstr Surg 2010;126:2268-2271. DOI: https://doi.org/10.1097/PRS.0b013e3181f619da

Sarwer DB, Crerand CE, Gibbons LM. Body dysmorphic disorder and aesthetic surgery. In: Nahai F. (ed.) The Art of Aesthetic Surgery: Principles and Techniques. Quality Medical Publishing, St. Louis, 2005;105.111.

Crerand CE, Phillips KA, Menard W, Fay C. Nonpsychiatric medical treatment of body dysmorphic disorder. Psychosomatics 2005;46:549-555. DOI: https://doi.org/10.1176/appi.psy.46.6.549

Phillips KA, Pagano ME, Menard W, Fay C, Stout RL. Predictors of remission from body dysmorphic disorder: a prospective study. J Nerv Ment Dis 2005;193:564-567. DOI: https://doi.org/10.1097/01.nmd.0000172681.51661.54

Veale D, Boocock A, Gournay K, Dryden W, Shah F, Willson R et al. Body dysmorphic disorder. A survey of fifty cases. Br J Psychiatry 1996;169:196-201. DOI: https://doi.org/10.1192/bjp.169.2.196

Javanbakht M, Nazari A, Javanbakht A, Moghaddam L. Body dysmorphic factors and mental health problems in people seeking rhinoplastic surgery. Acta Otorhinolaryngol Ital 2012;32:37-40.

Bellino S, Zizza M, Paradiso E, Rivarossa A, Fulcheri M, Bogetto F. Dysmorphic concern symptoms and personality disorders: a clinical investigation in patients seeking cosmetic surgery. Psychiatry Res 2006;144:73-78. DOI: https://doi.org/10.1016/j.psychres.2005.06.010

Phillips KA, Siniscalchi JM, McElroy SL. Depression, anxiety, anger, and somatic symptoms in patients with body dysmorphic disorder. Psychiatr Q 2004;75:309-320. DOI: https://doi.org/10.1023/B:PSAQ.0000043507.03596.0d

Cash TF, Phillips KA, Santos MT, Hrabosky JI. Measuring "negative body image": validation of the Body Image Disturbance Questionnaire in a nonclinical population. Body Image 2004;1:363-372. DOI: https://doi.org/10.1016/j.bodyim.2004.10.001

Veale D, Ellison N, Werner TG, Dodhia R, Serfaty MA, Clarke A. Development of a Cosmetic Procedure Screening Questionnaire (COPS) for Body Dysmorphic Disorder. J Plast Reconstr Aesthet Surg 2012;65:530-532 DOI: https://doi.org/10.1016/j.bjps.2011.09.007