Saddle Nose: Symptoms, Types, Causes and Treatment

Saddle nose is a distinctive deformity where the bridge of the nose appears sunken, creating both cosmetic and functional challenges for those affected. Beyond its visible appearance, saddle nose can lead to breathing difficulties and significant psychosocial impacts. This article explores the symptoms, classification, underlying causes, and the latest evidence-based treatments, merging clinical insights with patient-centered considerations.

Symptoms of Saddle Nose

Saddle nose deformity doesn’t just change the way a person looks—it can alter how they breathe and even how they feel about themselves. Early recognition of the symptoms is crucial for timely intervention and optimal outcomes.

Symptom	Description	Impact	Sources
Depressed Dorsum	Sunken or concave nasal bridge	Cosmetic, functional	2 4 8
Nasal Obstruction	Difficulty breathing through the nose	Functional	4 7
Tip Drooping	Downward or upward rotation of nasal tip	Cosmetic	2 9
Crusting/Congestion	Chronic nasal crusting, congestion	Discomfort	1

Table 1: Key Symptoms

Visible and Functional Changes

The hallmark of saddle nose is a depressed nasal dorsum—the bridge of the nose appears sunken or scooped out. This visually striking change can range from mild to severe, sometimes accompanied by widening of the bony bridge or a drooping tip 2 8 9. In some cases, the tip may even rotate upward, further exaggerating the deformity 8 9.

Breathing Difficulties

The loss of nasal support doesn't just affect appearance; it often leads to nasal obstruction. Patients may complain of persistent difficulty breathing through their nose due to the collapse of internal nasal structures 4 7. This can impact sleep, exercise, and overall quality of life.

Other Symptoms

Chronic nasal crusting and congestion may occur, particularly when saddle nose is related to inflammatory conditions like sarcoidosis 1. These symptoms can cause discomfort and further complicate management.

Psychosocial Impact

While not a "symptom" in the strict medical sense, the emotional and psychological effects of saddle nose are significant. The visible deformity may lead to self-consciousness or social withdrawal, highlighting the importance of holistic care.

Types of Saddle Nose

Saddle nose isn't a one-size-fits-all condition. Surgeons and clinicians classify this deformity by severity, underlying structural damage, and location—each influencing both prognosis and treatment strategy.

Type	Severity/Features	Key Treatment Approach	Sources
Minimal	Slight depression, minor loss	Extracorporeal rhinoplasty	5 6
Moderate	Noticeable sunken dorsum, some septal loss	Conchal grafts, structural support	5 6
Major/Severe	Marked collapse, loss of bony/cartilaginous support	Costal cartilage, major reconstruction	2 4 5 6
Progressive	Worsening deformity over time	Composite reconstruction, staged repair	2 4

Table 2: Common Types of Saddle Nose

Classification Systems

Multiple classification systems have evolved, aiming to guide treatment and predict outcomes:

• Three-Stage System: Minimal, moderate, and major, based on the degree of depression and structural loss 5.
• Type-Based Systems: Ranging from Type I (mild) to Type V (severe), factoring in the extent of septal and dorsal involvement 2 3 4.
• Modified Classifications: Some use four main types, with additional subtypes for progressive or complex cases 3 4 6.

Minimal and Moderate Types

• Minimal: Only slight depression of the nasal bridge; internal support is relatively intact. These cases can often be managed with less invasive techniques, such as extracorporeal rhinoplasty 5 6.
• Moderate: More pronounced deformity with partial loss of septal support. Surgical correction often requires conchal cartilage grafts or similar support techniques 5 6.

Major/Severe Types

• Major or Severe: Complete loss of support, affecting both cartilage and bone. The nose may appear dramatically flattened, with significant impact on breathing. Reconstruction typically involves costal cartilage grafts or other robust structural materials 2 4 5 6.

Progressive Deformity

Some cases are progressive, especially if the underlying cause remains active (e.g., autoimmune disease). These demand composite or staged reconstruction and close monitoring to ensure stable outcomes 2 4 6.

Causes of Saddle Nose

Understanding the root cause of saddle nose is essential—not only for effective treatment but also for prevention and long-term success. The etiology has shifted over time, reflecting advances in medicine and changes in societal patterns.

Cause	Mechanism/Example	Present-Day Frequency	Sources
Trauma	Nasal fractures, septal hematoma	Common	2 6 8 9
Surgery	Overresection during septoplasty/rhinoplasty	Increasing	2 6 8 9
Infection	Syphilis, leprosy, leishmaniasis	Rare (historically common)	8 9
Autoimmune	Sarcoidosis, relapsing polychondritis	Uncommon	1 6
Congenital	Genetic or developmental defects	Rare	9

Table 3: Main Causes of Saddle Nose

Trauma

Nasal trauma is the leading cause of saddle nose today. This includes not only acute fractures but also complications from septal hematoma—a blood collection inside the nose that, if untreated, can destroy cartilage and lead to collapse 2 6 8 9. High-speed accidents and sports injuries are significant contributors.

Iatrogenic (Surgical) Causes

Overresection of septal cartilage during rhinoplasty or septoplasty is increasingly recognized as a major cause 2 6 8 9. Surgeons are urged to exercise caution, as excessive removal of supporting structures can result in progressive saddle nose deformity.

Infectious Causes

Historically, syphilis and other infections (like leprosy or leishmaniasis) were leading causes of saddle nose, due to their destructive effects on nasal cartilage and bone 8 9. With modern medicine, these have become rare in developed countries, though they still occur in some regions.

Autoimmune and Inflammatory Diseases

Conditions such as sarcoidosis and relapsing polychondritis can erode nasal cartilage, leading to saddle nose 1 6. These cases can be challenging, as the deformity may progress if the underlying disease isn’t controlled.

Congenital and Miscellaneous Causes

Rarely, saddle nose can result from congenital defects or certain racial features that predispose to a lower nasal bridge 8 9. These are typically managed with individualized reconstructive approaches.

Treatment of Saddle Nose

Treatment of saddle nose is both an art and a science, seeking to restore both form and function. Advances in surgical techniques and materials have broadened the options, allowing for highly tailored repairs.

Treatment	Technique/Material Used	Best For	Sources
Augmentation	Dorsal onlay grafts (cartilage, bone, synthetics)	Mild to moderate cases	5 6 8 9
Septal Reconstruction	Extended spreader/caudal grafts, L-strut	Moderate to severe cases	2 3 4 6
Composite Reconstruction	Deep structural and aesthetic layers	Progressive/complex	2 4 6
Autografts/Homografts	Costal cartilage, conchal cartilage	Long-term stability	3 5 6 9 10
Alloplastic Implants	Polyamide mesh, silicone, etc.	Select cases	8

Table 4: Treatment Modalities

Principles of Treatment

The main goals in treating saddle nose are to:

• Restore the aesthetic dorsal contour
• Re-establish structural support (to prevent re-collapse)
• Improve or maintain nasal function (airway)
• Minimize risks of complications and need for revision 2 3 4 7

Augmentation Techniques

For mild to moderate deformities, dorsal augmentation with cartilage (autograft from the patient’s own body) or synthetic materials can achieve excellent cosmetic results 5 6 8 9. Conchal (ear) cartilage is often used for moderate cases, while costal (rib) cartilage provides robust support for more severe deformities 5 6 9.

Alloplastic implants such as polyamide mesh or silicone have been used, especially in cases where autologous tissue is insufficient or not desired 8. These materials can provide immediate contour but carry risks of infection or extrusion.

Septal and Structural Reconstruction

Major septal reconstruction is often needed for more severe or recurrent saddle nose 2 3 4 6. Techniques include:

• Extended spreader grafts
• Caudal extension grafts
• Extracorporeal L-strut (rebuilding the septum outside the body, then reimplanting)
• Composite reconstructions that integrate deep structural and surface aesthetic layers 2 4 6

These complex repairs aim to restore both the supportive nasal framework and the external contour, often requiring significant surgical expertise.

Management of Underlying Disease

In cases due to autoimmune or inflammatory diseases, such as sarcoidosis or relapsing polychondritis, medical management of the underlying disease must be optimized before surgery 1 6. Surgery is generally safe if the disease is well-controlled.

Revision Surgery and Outcomes

Despite advances, revision surgery may be needed if the deformity recurs, grafts warp, or infection develops 3 4. Success rates have improved, but saddle nose remains a challenging problem, particularly in severe or progressive cases 3 6.

Conclusion

Saddle nose deformity is a complex condition, affecting both appearance and nasal function. Its management requires a thorough understanding of the underlying causes, careful classification of severity, and selection of the most appropriate reconstructive techniques. With advances in surgical materials and methods, most patients can expect significant improvement in both appearance and breathing—though the challenge remains greatest in severe and progressive cases.

Key points:

• Saddle nose is characterized by a sunken nasal bridge, leading to both cosmetic and functional issues 2 4 8.
• Symptoms include visible depression, nasal obstruction, and tip changes, with significant psychosocial impacts 2 4 9.
• The condition can be classified by severity and structural loss, guiding treatment options 2 4 5 6.
• Causes range from trauma and surgery to infections and autoimmune diseases 1 2 6 8 9.
• Treatment is tailored to severity: mild cases may need only augmentation, while severe cases require major reconstruction using cartilage grafts or synthetic implants 2 3 4 5 6 8 9.
• Successful outcomes depend on restoring both nasal structure and function, with careful management of underlying disease when present 1 6.
• Despite surgical advances, saddle nose remains one of the most challenging deformities in nasal reconstruction 2 3 4 6.

By understanding the nuances of this condition, patients and clinicians can work together to achieve the best possible outcomes.