|Year : 2017 | Volume
| Issue : 3 | Page : 144-151
Direct Anthropological analysis of Unilateral Cleft Nose: A Novel Approach using an Innovative Plane
Sanchit Jain1, Gunjan Dube2
1 Dube Surgical and Dental Hospital, Jabalpur, Madhya Pradesh; Department of Oral and Maxillofacial Surgery, Hitkarini Dental College, Jabalpur, Madhya Pradesh; Hitkarini Dental College, Jabalpur, Madhya Pradesh, India
2 Dube Surgical and Dental Hospital, Jabalpur, Madhya Pradesh; Department of Oral and Maxillofacial Surgery, Hitkarini Dental College, Jabalpur, Madhya Pradesh, India
|Date of Web Publication||21-Nov-2017|
Dube Surgical and Dental Hospital, Ghmapur Chowk, Near High Court, Jabalpur - 482 001, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Objective: The main objective of this study is to introduce a new plane for direct anthropological study of the nose. Design: The study is a cross-sectional study done to analyze cleft nasal deformity by direct method and comparing with indirect method for assessing reliability of the plane introduced. Setting: The study was carried out in institutional setup which is approved for smile train cleft project. Inclusion Criteria: The study included only those patients who were affected with unilateral cleft lip isolated or associated with cleft palate. All the patients who were included in the study were aged above 15 years where the growth of the nose was completed. Exclusion Criteria: Patients who are aged below 15 years of age, whose growth is yet not complete. Main Outcome Measure(s): There had been no specific plane to analyze the angle of columella in recent past which has been mostly analyzed by indirect methods (photographic method and three-dimensional scans). We have attempted to introduce a new plane for analysis of nose anthropologically both using direct method and compared it with the indirect method for its reliability. Results: Comparative assessment with indirect method shows a little variation in recording which is not statistically significant, thus ensuring the reliable application of this particular technique for evaluating cleft nasal deformity. Conclusions: The technique described is easier to apply and replicate in limited resource setup as it does not require high-end armamentarium and equipment.
Keywords: Analysis of nose, anthropometry, cleft lip, direct anthropology, nose
|How to cite this article:|
Jain S, Dube G. Direct Anthropological analysis of Unilateral Cleft Nose: A Novel Approach using an Innovative Plane. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:144-51
|How to cite this URL:|
Jain S, Dube G. Direct Anthropological analysis of Unilateral Cleft Nose: A Novel Approach using an Innovative Plane. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2022 Aug 9];4, Suppl S1:144-51. Available from: https://www.jclpca.org/text.asp?2017/4/3/144/218872
| Introduction|| |
The evaluation of the nose for symmetry and any minor abnormalities by mere observation with our eyes is the simplest thing but to put the same in terms of exact values and calculation of the minor changes is more complicated than assumed. Various authors have used either a difficult direct method or a relatively simpler indirect method to analyze the nose.,,,,,, The difficulty in case of indirect technique lies in the standardization of the dimensions of nose and standardization of the method of recording values.,,,,, The severity of the secondary deformities of nose is highly variable in orofacial clefting. These deformities can be corrected by various surgical modalities. Hence, there lies a need to objectively evaluate the deformity and the outcome of the surgery. Hence, there is a need for easier methods for directly evaluating the form and symmetry. The aim of our study was to establish a direct method of analysis, the axis of the nose without advanced equipment, and technology for the assessment of the degree of axis change in the nose. The landmarks used are easier to replicate and be standardized making it simpler.
The results that were obtained by analysis which was carried out by direct method was then compared with the results which were obtained by indirect method of analysis. The indirect analysis was done using standardized photographs of the patients who were included in the study with the help of the Adobe Photoshop CS6 extended version software.
| Materials and Methods|| |
The study included those patients who had congenital unilateral cleft lip with/without cleft palate who reported for rhinoplasty from January 2014 to December 2016. All the patients who were included in the study were aged above 15 years and nonsyndromic on clinical examination. All the patients had attained puberty, and their growth spurts were over so that any variation in the readings does not occur. The growth of nose and changes of the nasal characters get almost finished by 15 years and hence were considered for inclusion in the study.
Those patients who were aged below the age of 15 years were not included in the study. Those patients who were affected with bilateral cleft deformity and midline deformity were excluded from the study.
A total of 10 patients were included in the study who reported to the department for the secondary nasal deformity correction.
The materials that were used for the analysis of the nose in our study included the use of Vernier caliper, metric scale, and scientific mathematical calculator for direct anthropological analysis to determine and validate the nasal axis.
The photographs were used for the indirect analysis which were taken with Canon Powershot G15 with 12 megapixel image resolution and magnification of ×5. The photographs were then analyzed digitally with the help of the Adobe Photoshop CS6 extended version software (Adobe Systems Inc.,) to evaluate the axis of the cleft nose.
The study has two components. The first component was usage of direct method as described below for determining the axis of the nose directly on the patient. The second component was determination of the axis of the nose by indirect method by using standardized photographs as described. Reading were taken for all parameters by two different observers. Variations between the observers were calculated for level of significance. This was done to determine the ease of reproducibility of the landmarks used in the study. The results obtained were tabulated and statistically analyzed for interobserver significance and also for significance of reliability of the columella angle assessed between direct and indirect method.
Determination of anatomic landmarks and the planes by direct method
The specific landmarks which were easily replicated were used for the analysis. The alar curvature (ac) points which were earlier described were marked on both cleft side and on the noncleft side. The ac point is located in the far lateral basal part of the ala. The point on the cleft side was named as acC and the point on the normal side of the nose was termed as caN. These point were then joined to form a plane. This plane is referred as reference plane (R). All the further measurements were carried from the reference plane to other landmarks on the nose.
A line is introduced for the analysis of nose which initiated from the columella apex point and travelled posteriorly till the reference plane dividing the columella of the nose into two equals. The columella apex point is the most prominent point on the columella which is marked first followed by division of the cleft columella. The anterior nostril determining point is the most prominent anterior point on the nostril which is identified and marked. These points then help in the determination of accuracy of division of the columella of the nose. This is done by marking a point which is exact midpoint on the line joining the anterior nostril determining point on both sides. The point is determined by calculating the total distance from nostril determining points anteriorly and dividing that line into equal halves and hence providing with one more specific clinical point which is determined on the patient to avoid chance of any error in the determination of plane. The line is then made which connects both the columella apex point and the arbitrary midpoint (mNp) which is further extended to join the reference plane. This line was termed as columella plane (C). The length of this plane is then determined and noted down from columella point till the point of intersection with the reference plane.
The perpendicular line is then marked from the reference line from the point where the columella plane joined the reference plane such that it is perpendicular to the reference line. This line was termed as perpendicular plane (P). A point on the perpendicular line which is marked on the nose such that when an arbitrary line (A) is drawn, it is perpendicular to the predetermined columella plane line as shown in [Figure 1]a,[Figure 1]b,[Figure 1]c. The length was then calculated for this perpendicular plane with help of Vernier caliper as shown in [Figure 1]c and tabulated in [Table 1].
|Figure 1: Direct method of analysis of the columella angle. (a) Patient photograph showing the marking for nasal analysis. (b) Patient photograph showing the recording of the lengths for analysis with help of Vernier caliper. (c) Hand diagram showing various markings along with the planes. naN: Anterior nasal determining point on normal side, naC: Anterior nasal determining point on cleft side, mNP: Midpoint of the line joining the naN and naC, acN: Alar curvature point on normal side, acC: Alar curvature on the cleft side, R Plane (reference plane): Line joining the acN and acC, caP: Columella apex point, C plane (columella plane): The columella plane is line joining the mNP to the reference plane (R), AP: Arbitrary point is formed by a line perpendicular line to columella plane (C). The plane is marked as perpendicular plane (P), A plane: Arbitrary plane perpendicular to the reference line. (d) The trigonometric formula used for the calculation of the angle|
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|Table 1: All the values recorded for determining the columella angle in direct method and the columella angle which was determined by the indirect method|
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Calculation of the axis of nose in direct method
The three plane, i.e., the columella plane, perpendicular plane, and the arbitrary line when connected forms a right-angled triangle. This forms the basis of determining the axis of the projection and long axis of the nose from the base of the nose. Columella angle is calculated which is the angle formed between the columella plane and the perpendicular plane. The columella angle is calculated using the trigonometric formula. The perpendicular plane is actually perpendicular to the reference plane, but the perpendicular length is taken only till the point on the lobule of the nose where the arbitrary line that is drawn from the columella plane which is perpendicular to it intersects the perpendicular plane to form a right-angled triangle. The following formula was used for the calculation
Angle of columella = cos−1 perpendicular length/columella plane length [Figure 1]d.
The arbitrary line also could be used for the determination of the nasal axis but was not used for the following reasons:
- The distance between the arbitrary point and the columella plane point was relatively less and hence made it difficult to be accurately measured
- Even minor changes in the measurement cause a wide range of errors when the trigonometric formula is used because the trigonometric formulas are highly sensitive to minor changes in the readings which were recorded
- With the increase in the distance recorded, there is less error in the reported/measured value which indirectly reduces the error in the final results obtained after using the trigonometric formula
- With the increase in the value used in the trigonometric formula, the variation between the results obtained is reduced drastically.
Attempt to validate the anthropological method by indirect method
The plane introduced in the direct analysis was validated with the help of indirect photographic method [Figure 2]. The axis of the nose was determined on the photo by marking the same landmarks. The recorded angles were charted and then statistically compared to the angles recorded by the anthropological methods and statistically evaluated.
The standardization of the photographs which were taken for the indirect analysis was done in accordance with the description of the submentovertex view given by Ettorre et al., in their key article which extensively discussed about digital photography and its advantages and method to use it for analysis of the face. In our study, standardization was done by tilting the patients head back so that the alar domes are below the eyebrows but above the canthi. The neck of the patient was flexed such that the nasion (midpoint on nasal bridge) and the midpoint on the chin and the most prominent point of thyroid cartilage remain in line with each other. The photograph was then taken with the digital camera. The reliability of these photographs for the indirect analysis of the nose has been earlier established by other authors in the past. These photographs were then analyzed with the help of the software mentioned earlier to determine the axis of the nose.
Calculation of the axis of nose in indirect method
The photograph is analyzed in detail and the previously mentioned landmarks were marked on the photograph of the patient. The line joining the upper nostril determining points on the left side and right side was drawn with the help of line tool and measured with the measurement tool. Exact midpoint was marked on the line. The columella apex point was then marked on the nose. The reference line was then drawn on the photograph. The perpendicular line was then drawn to this reference line. After determining both the planes, the exact angle between the two planes is measured by tracing the columella plane, then creating a protractor by alt-drag (drag holding [Alt] key pressed) and tracing the perpendicular plane [Figure 2]. The on-screen angle which is shown is then tabulated for all the patients [Table 2].
|Table 2: Calculated columella angle in direct method and the columella angle which was determined by the indirect method (photographic method) by each observer|
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The sample size of 10 patients was taken as advised for adequacy and reliability of results by statistician. Mean, standard deviation, minimum and maximum values of columella angle by direct and indirect methods were calculated. Interclass correlation coefficient was calculated to show that columella angle values were in almost perfect agreement in both the terms of interobserver variation in values calculated and the intraobserver calculated values. All analyses were performed using version 21.0 of the Statistical Package for Social Sciences (IBM Corporation, Armonk, New York, USA).
| Results|| |
All the columella angle values calculated by direct method and indirect method by both the observers are tabulated in [Table 2]. The variations in the determination of the anatomic landmarks between both the observers led to a minimal differences in the calculated columella angle in both direct and indirect method. This is evaluated with the interclass correlation coefficient test and was found to be statistically in almost perfect correlation between both the observers. The columella angle determined by direct and indirect method was also evaluated statistically between both methods and were also found to be in almost perfect agreement with each other [Table 3] and [Table 4].
|Table 3: Intraexaminer reliability of columella angle measured using direct and indirect method|
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|Table 4: Interexaminer reliability of columella angle measured using direct and indirect method|
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These results conclude the following:
- There is minimal differences observed during the interpretation of the landmarks and the perpendicular plane, but this difference is not significant, and the interpretation between both the observers is in almost perfect agreement
- There is no significant difference between columella angle calculated by either direct or indirect method.
Thereby, stating that the plane which is introduced in our study could be used with adequate reliability for assessing the change in the axis of the nose and hence determining the net deformity of the cleft lip-nose. Thereafter, the same plane can be used to determine degree of change of corrective procedures of nose and also the stability of any such procedure performed.
| Discussion|| |
The cleft lip nasal deformity is a challenge to an oral and maxillofacial surgeon due to the extent of variability of the deformity and also the complexity of the deformity which has been well-established fact and most extensively studied.,,,,, The major factors that contribute to the deformity are congenital anatomic deficiency, surgical scarring, and mechanical stress across the defect due to growth.,
There has been extensive analytical study on the analysis of cleft nasal deformity, which has been shifted from the direct method to that of indirect or photographic method owing to difficulty in replication of the exact landmarks that have been used for the recording of the measurements. In this article, we are discussing an innovative plane which is introduced for direct anthropological analysis which never assessed the columella angle and the extent of deviation in the past. The landmarks chosen are reliable and easily replicable as evident from the statistical analysis of the interobserver findings.
Direct anthropometry had many advantages which included the accuracy of the results obtained and acceptability, but the disadvantages include the fact that the replication of the exact landmark is difficult, cannot be used in growing patients, and interpersonal changes in the landmarks that are used for assessment which was not evident in our study. Owing to these disadvantages, Farkas in 1980 concluded that “photometry” eliminated such drawbacks and can be used for indirect analysis. This formed the basis of our comparison of new plane which was introduced for direct anthropological analysis with indirect analysis.
The earliest detailed reports of anthropological analysis of cleft lip-nose deformity were done by Tanner and Weiner in 1949. Farkas and Lindsay used direct method for anthropometry of the cleft nasal deformity extensively for years which was first reported in 1971. The analysis which was done by them was continued till the year 1980. Even this detailed analysis had few missing assessments which were further added on by Toppiard in 1985. Even then, the assessment of the columella angle was still missing the method of which is innovated in our article.
Pigott in 1985 was the first to understand the need for assessing the nose from basilar view for critical assessment of long-term results of cleft surgery. This led to revolution and further attempts by various authors to use photographs for indirect anthropometric analysis.
Kohout et al. in their landmark article where they extensively analyzed cleft nasal deformity by photographic analysis concluded that photographs are sensitive to the angle from which they are taken as well as the distance and focal length of lens used. Even after so much sensitivity, these can be extensively be of use in analysis of ratios and also for angular measurements as they are not affected by magnification. He also emphasized on standardization of the photographs used for such analysis. These understandings of the photographic analysis hence acted as basis for comparison and validating the replication of the new plane in our study.
Becker and Tardy in 1990 attempted the first to standardize these photographs for facial analysis. These standardization hence could help in proper and more accurate assessment of the normal face along with the results of various procedures carried out on face.
Moss et al. in 1991 introduced the application of the three-dimensional (3D) analysis for assessing the facial asymmetry which rapidly gained acceptance. This however was more technical and also involved usage of machinery which was costly. Owing to these factors, 3D analysis was not followed until the advent of more cheaper and cost-effective method of obtaining the image was discovered. The cleft nasal deformity was been analyzed in detail with intercleft groups, control groups, and also with the details of the extent of the deformity at different intermediate time periods without extensive standardization of the photographs. Many others in the past have earlier discussed columella height, projection of the tip of nose, nostril height, lobule ratios, ratios of the cleft nostril length and width, and alar bases which were examined in detail along with ratios in the intermediate time period.,,,
After the landmark analysis by Hood et al. in 2003, 3D scans were used extensively for the analysis of the cleft nasal deformity. This was then extensively studied as various methods of using 3D data were introduced and were more cost-effective also making it feasible to acquire these data. The data were assessed extensively by other authors which were obtained by various modalities ranging from computed tomography (CT) scans to laser surface scanning.,, The cleft nasal deformity analysis was been carried out on the basal view in photographic analysis and 3D analysis owing to the facts which were documented previously by other authors.,,,,, The patients affected from cleft in India mainly come from poorer strata, and hence, such 3D analysis is not affordable by most of the patients. The assessment of columella on direct anthropological would hence be beneficial both for the patient and the operating surgeon to understand the extent of deformity even without going for trouble of standardization of photographs or 3D analysis on the basis of analysis which could be carried out by our new plane.
Ettorre et al. extensively studied the various photograph taken in the submental view and standardized the technique of taking submentovertex photographs of the patient. Still minor errors were evident even after such standardization of photographs, lead to advent of other techniques to standardize photographs which used the various landmarks. The advent of digital photography aided in using organs such as ear and other facial structures which were properly superimposed for accuracy. This made the use of photographic analysis more tedious and the authors again shifted their interest to 3D analysis. After 2008, authors extensively used 3D CT scan images or laser scanning of face for analysis of these facial deformities.,, In all the studies which were carried out in the past, there was no introduction of the direct method to assess the columella angle. The reliability of this plane is adequately supported with the indirect analysis and hence can be used to its maximum potential. The direct method can be used extensively because it does not have additional costing for analysis and also does not need the standardization as needed in other studies.
Modified columella plane length
This plane introduced in this article has not been discussed by other authors earlier. We have used this plane to connect the infratip projection of the columella to that of the reference plane. Columellar plane was used in the earlier studies were drawn from the lobule to the reference plane on photographic method which was be easily replicated for analysis on the submentovertex view. Another description of the plane was the line joining the columella point to that of subnasale which could be used for direct analysis. The plane introduced in our study was modified on the fact that it had to be replicated. The other point which was marked on the midway on the line joining the nostril determining point on the cleft side and noncleft side was taken to avoid bias in marking of the modified columella plane and easier replication of the plane.
Due to intrinsic activity of the muscle and the extent of the deformity in both the skeletal component and the cartilaginous framework, there is change in the axis of the nose. This has been described earlier by Fisher and Mann in 1998 and also the latest model which has been described by Nakamura et al. in 2010, makes it well established that the nasal angle is deviated toward the cleft side due to the septal deviation along with the alveolar bone defect on the cleft side. Due to the preexisting defect or hypoplasia of the maxillary bone even after grafting, the tendency of the relapse of the nasal tilt could be easily understood. The determination of the nasal axis would help the surgeon to determine the extent of the deformity which the patient attains and also helps the surgeon for providing a tailored surgical treatment. The columella angle which is determined in the study aims at determining the loss of projection of the nose in relation to the base of the nose which is already at a plane from that of the normal axis due to hypoplasia of maxilla at the cleft side and hence the extent of correction can be achieved at maximum.
Clinical significance of the introduced plane
The introduced plane has the following clinical significance:
- The plane is easily replicable and determines the extent of deformity which is in measureable values and also helps in determination of the extent of correction needed
- Can act a basis for understanding the exact measurement of the correction which takes place when compared with pre- and post-operative cases of rhinoplasty and also be used for analyzing the extent of relapse of the correction done
- The degree of deviation can be determined without need for much standardization and technical support such as in photography or 3D CT scans. The clinical assessment could be done in measurement directly.
| Conclusion|| |
The planes which were used in the analysis of the nose are reliable and easily replicable. These can be used to determine the angular measurements involving the cleft nasal deformity exclusively in those clinical setups where the availability of resources is limited. The use of these parameters in limited resource setup help to validate and evaluate the clinical case outcome and enhance documented objective evidence to the procedure being performed, although there was a little margin of error when these calculations were done with the use of manual Vernier caliper as it was constantly observed. This variation of the error is due to the use of trigonometric formula which is highly sensitive to minor changes in the readings obtained during the analysis of the cleft nasal deformity. The same can be overcome by substituting the manual caliper with an electronic Vernier caliper which can be evaluated further by subsequent studies. Most of the indirect methods of analysis requires hectic standardization of 3D analysis whereas this direct method has taken less time compared to the other preverified methods in the literature and hence is preferred by us for analysis of the cleft nose.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We would like to thank Dr. Sudhanshu Saxena for his immense support for statistical work related to this study, Dr. Sneha Patil for her help in making out the hand diagrams, and Mr. Mayank Jain who has helped to analyze the photographs which were taken for indirect anthropometric analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]