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A twin-center study of nasal tip numbness following septorhinoplasty or rhinoplasty.

Introduction

Nasal tip numbness is a recognized postoperative complication after septorhinoplasty and rhinoplasty. However, very few studies of the incidence of temporary or permanent nasal tip numbness have been published. Research on the precise methods of surgery associated with this outcome is also lacking.

If the choice of specific surgical procedure were found to influence the risk of complications, the decision could have important medicolegal implications. In a retrospective study of 200 rhinoplasty cases, McKinney and Cook reported that 1 of those patients instituted a lawsuit seeking damages for postoperative hypoesthesia of the nose. (1)

We conducted a study to determine the incidence and duration of nasal tip numbness after primary septorhinoplasty or rhinoplasty. We also sought to determine if the type of surgical approach was associated with the risk of complications.

Patients and methods

We conducted a retrospective, twin-center study at two large university teaching hospitals in London. We reviewed the case notes of 155 primary septorhinoplasties or rhinoplasties that had been performed at these two centers during a period of nearly 3 years. We excluded from our study population all patients 14 years of age or younger and all who had previously undergone nasal surgery. This left us with 93 patients who met our eligibility criteria.

In addition to demographic data, we compiled information on the indication for surgery, any relevant medical history (e.g., atypical facial pain) or drug history (e.g., cocaine abuse), descriptions of the intraoperative details of surgery, complications, and the time of surgery. At each center, the surgeries had been performed by one appointed departmental rhinology consultant. Both surgeons were of similar experience and seniority.

To obtain our study data, two otolaryngologists contacted patients by telephone to ask about their postoperative experience. If there was no answer initially, patients were telephoned a second time. The otolaryngologists asked questions about the presence or absence of nasal tip numbness, the duration and severity of numbness, and whether it resolved. Both used the same list of questions, with clarification given if a patient did not understand a question. All of the patients had been made aware of the possibility of tip numbness as a complication before surgery. For the purposes of our study, the duration of short-term tip numbness was defined as less than 6 months postoperatively, and long-term numbness was defined as anything beyond 6 months.

The otolaryngologists were able to contact 65 of the 93 patients-31 males and 34 females, aged 15 to 67 years (mean: 30.5). A total of 32 patients had been treated at center 1 and 33 at center 2. Septorhinoplasty had been performed on 52 patients and rhinoplasty on 13. Both closed (endonasal) and open surgical approaches were used (n = 50 and 15, respectively). The length of time between surgery and the follow-up phone calls ranged from 6 to 37 months.

The data were analyzed on a Microsoft Excel spreadsheet (Microsoft Corp.; Redmond, Wash.).

Results

A total of 17 patients experienced nasal tip numbness initially, for an overall complication rate of 26.2% (table 1).

By 6 months postoperatively, 10 patients (15.4%) had experienced a resolution of their numbness, and their complication was classified as short term. In fact, 8 of these 10 cases had resolved within 2 weeks.

The remaining 7 patients (10.8%) had experienced long-term numbness (tables 2 and 3). Of these 7 patients, 6 reported severe numbness that persisted beyond 8 months, and 1 patient described mild numbness for at least a year. One of the 6 with severe numbness, a middle-aged woman, was particularly distressed by her symptom, but she did not pursue any legal action.

The rates of tip numbness were comparable in the two centers in terms of both closed and open surgical approaches (table 1). All patients who reported tip numbness after an open-approach rhinoplasty experienced it for more than 6 months (i.e., over the long term). Also, there appeared to be a slight trend toward long-term tip numbness occurring more often in women (5 of 34 [14.7%]) than in men (2 of 31 [6.5%]), but these numbers are obviously small (tables 2 and 3). Ethnicity did not appear to influence the risk of developing tip numbness.

Two patients who experienced tip numbness experienced further complications; 1 developed a callus on the nasal bridge, and the other experienced a postoperative nasal infection, and both underwent revision surgery. Among the patients who did not experience tip numbness, 2 patients developed complications; 1 developed a columellar scar, and 1 experienced a slipped dorsal implant. According to the Fisher exact test, differences in overall complication rates could not be attributed to the type of surgical approach used (figure).

Discussion

The nasal tip receives its main sensory supply from the external nasal branch of the anterior ethmoid nerve, which is a branch of the nasociliary nerve. This branch, also called the external nasal nerve, emerges between the nasal bone and the upper lateral cartilages. Transection of the nerve usually occurs during intercartilaginous dissection. (2-4) The nasal tip is also supplied by branches of the infraorbital nerve.

In a study of 75 patients, Thompson found that 49 of them (65.3%) experienced some degree of sensory change in the nasal tip after rhinoplasty. (5) This figure included not only tip numbness, but increased sensitivity and tenderness, as well; initial numbness was reported as the only sensory change in 22 patients (29.3%). This complication appeared to be more likely in cases of nasal tip reduction than other types of surgery. Thompson's results are comparable to ours in that our rate of initial numbness was 26.2%.

Bafaqeeh and Al-Qattan in Saudi Arabia investigated alterations in nasal tip sensation in 25 patients. (6) Their study group had undergone subjective questioning, as well as objective testing, of nasal sensation with Semmes-Weinstein monofilaments at 3 weeks and 1 year after open rhinoplasty. All of these procedures were cosmetic, and most involved a tip-plasty. All 25 patients reported an initial subjective alteration (e.g., "diminished sensation," "nose felt different"), and all 25 patients recovered their nasal sensation by 1 year postoperatively. The difference between their findings and ours might be attributable to the way the questions were worded; we specifically asked about "numbness" and the "nose feeling frozen" rather than "pain" or "feels different."

McKinney and Cook reported that a significantly higher percentage of females than males were dissatisfied after rhinoplasty. (1) The incidence of dissatisfaction increased among those in the fifth decade of life. Our study found a similar trend.

Han et al carried out a cadaveric anatomic study of the external nasal nerve. (2) They found that the nerve's point of exit from the distal nasal bone was located 6.5 to 8.5 mm lateral to the nasal midline. Most of the nerves (95%) passed through the deep fatty layer directly under the layer of the superficial musculoaponeurotic system (SMAS). Patterns of nerve branching were also observed. Their study illustrated that not only can the external nasal nerve be severed during endonasal incisions, but it also may be damaged during hump removal or dorsal nasal augmentation with implants that require extensive dissection of the soft tissue around the upper lateral cartilages and nasal bones.

It is interesting that our study demonstrated that nasal tip numbness occurred even after open surgeries in which intercartilaginous incisions were not made. This implies that tip numbness can occur secondary to causes other than the division of the nerve. Possible reasons for this include the raising of the soft-tissue envelope itself or the disruption of the vascular supply to the tip. Also, variations in the anatomy of each nerve among different patients may be a contributing factor.

Studies have generally found a resolution of tip numbness within 1 year of surgery. (2,5,6) This is thought to be the result of either (1) the resolution of neuropraxia in the external nasal nerve or (2) collateral sprouting from the nerves that supply the adjacent areas of skin. (7)

One drawback to our study is that the number of eligible patients whom we were able to contact (N = 65) was relatively small. Other weaknesses were the retrospective nature of the study, the possibility of recall bias, the qualitative nature of the data, and the lack of objective evidence of nasal tip numbness. With regard to recall bias, Sale et al demonstrated that patients exhibit a high degree of inaccuracy when trying to recall symptoms 1 year after a precipitating event. (8)

Another possible confounding variable is that the surgeries were performed by two different surgeons. However, (1) the two surgeons were of similar grade and experience, (2) the number of procedures performed and the approaches used were similar, and (3) the rates of postoperative tip numbness were similar.

In conclusion, nasal tip numbness is a recognized complication of septorhinoplasty and rhinoplasty surgery. Few studies have reported the complication rate or identified possible factors that contribute to this complication. Our results correlate well between sites and with those in the published literature. In terms of surgical technique, it is generally advised to dissect in the sub-SMAS layer directly onto cartilage.

Based on our study, the risk of developing nasal tip numbness may be quoted as 26% in the initial postoperative period, 15% in the short term, and on average 11% in the long term (i.e., >6 mo) with either type of approach. This would be reasonable for the purposes of preoperative consent.

Given the paucity of available evidence on postoperative tip numbness, we hope that our study contributes to surgeons' and patients' awareness of this complication and will serve as a stimulus for further research in the area.

References

(1.) McKinney P, Cook JQ. A critical evaluation of 200 rhinoplasties. Ann Plast Surg 1981; 7 (5): 357-61.

(2.) Han SK, Shin YW, Kim WK. Anatomy of the external nasal nerve. Plast Reconstr Surg 2004; 114 (5): 1055-9.

(3.) Daniel RK, Regnault P, eds. Aesthetic Plastic Surgery: Rhinoplasty. Boston:Lippincott Williams & Wilkins; 1993:10.

(4.) Zide BM. Nasal anatomy: The muscles and tip sensation. Aesthetic Plast Surg 1985; 9 (3): 193-6.

(5.) Thompson AC. Nasal tip numbness following rhinoplasty. Clin Otolaryngol Allied Sci 1987; 12 (2): 143-4.

(6.) Bafaqeeh SA, Al-Qattan MM. Alterations in nasal sensibility following open rhinoplasty. Br J Plast Surg 1998; 51 (7): 508-10.

(7.) Aszmann OC, Muse V, Dellon AL. Evidence in support of collateral sprouting after sensory nerve resection. Ann Plast Surg 1996; 37 (5): 520-5.

(8.) Sale H, Hedman L, Isberg A. Accuracy of patients' recall of temporomandibular joint pain and dysfunction after experiencing whiplash trauma: A prospective study. J Am Dent Assoc 2010; 141 (7): 879-8.

From the ENT Department, Christchurch Hospital, Christchurch, New Zealand (Miss Jaberoo); the ENT Department, Guy's Hospital, London (Mr. De Zoysa); the Royal National Throat, Nose and Ear Hospital, London (Mr. Mehta); the Department of ENT-Head and Neck Surgery, Ng Teng Fong General Hospital, Singapore (Mr. Prasad and Miss Heywood); the Department of Otolaryngology, Charing Cross Hospital, London (Mr. Saleh); and the ENT Department, Northwick Park Hospital, London (Mr. Marais). The study described in this article was conducted at Charing Cross Hospital and Northwick Park Hospital.

Corresponding author: Miss Marie-Claire Jaberoo, ENT Department, Level 5 Christchurch Hospital, 2 Riccarton Ave., Christchurch 4710, New Zealand. Email: mcjaberoo@gmail.com

February 24, 2016 by Marie-Claire Jaberoo, MRCS; Neil De Zoysa, MRCS; Nishchay Mehta, MRCS; Vyas Prasad, FRCS(ORL-HNS); Rebecca Heywood, MRCS; Hesham Saleh, FRCS(ORL-HNS); Joe Marais, FRCS(ORL-HNS)

Caption: Figure. Graph shows the short- and long-term nasal tip numbness rates with the closed and open surgical approaches. The number of short-term cases includes patients with long-term numbness.
Table 1. Incidence of tip numbness according to center and surgical
approach *

                             Center 1   Center 2

Closed approach, n           24         26
Short term numbness, n (%)   9 (37.5)   6 (23.1)
Long-term numbness, n (%)    3 (12.5)   2 (7.7)

Open approach, n             9          6
Short-term numbness, n (%)   1 (11.1)   1 (16.7)
Long-term numbness, n (%)    1 (11.1)   1 (16.7)

* The number of short-term cases includes patients with long-term
numbness.

Table 2. Selected characteristics of the cases of long-term tip
numbness

Pt.   Center   Age/sex   Ethnicity   Type of surgery    Approach

1     2        65/M      White       Septorhinoplasty   Open
2     2        41/F      Nonwhite    Septorhinoplasty   Endonasal
3     2        21/F      White       Septorhinoplasty   Endonasal
4     1        19/M      Nonwhite    Rhinoplasty        Open
5     1        30/F      Nonwhite    Rhinoplasty        Endonasal
6     1        31/F      White       Septorhinoplasty   Endonasal
7     1        27/F      White       Septorhinoplasty   Endonasal

Table 3. Additional characteristics of the cases of long-term tip
numbness

Pt.  Osteotomy    Tip work          Valve work

1    --           --                Bilateral
                                    spreader grafts,
                                    lateral crural
                                    strut grafts

2    Lateral      Domal sutures,    --
                  cephalic strips

3    Lateral      Supratip graft    --

4    Lateral      --                --
     and medial

5    Lateral      --                --

6    Lateral      --                --
     and medial

7    Lateral      Caudal strut      --
     and medial   graft

Pt.  Dorsum    Implant

1    --        --

2    Hump      --
     removal

3    Hump      No, but
               polydiaxanone
               foil was secured
     removal   to the septum

4    Hump      --
     removal

5    Hump      --
     removal

6    --        --

7    Hump      --
     removal
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Article Details
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Author:Jaberoo, Marie-Claire; de Zoysa, Neil; Mehta, Nishchay; Prasad, Vyas; Heywood, Rebecca; Saleh, Hesha
Publication:Ear, Nose and Throat Journal
Article Type:Report
Date:Feb 1, 2016
Words:2161
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