key: cord-0693611-lc4168sd
authors: Zhu, Daniel; Tham, Tristan; Georgolios, Alexandros
title: Saddle nose deformity and nasal airway obstruction, as a complication of COVID-19, in a patient with a remote history of septoplasty: A case report
date: 2022-03-26
journal: Otolaryngol Case Rep
DOI: 10.1016/j.xocr.2022.100428
sha: 6fd9dc2562deaad6f36f266edc5dfcd5b29ce07c
doc_id: 693611
cord_uid: lc4168sd

INTRODUCTION: Although the effects of SARS-CoV-2 (COVID-19) infection in olfaction have been well established, there is relative paucity of information on possible other complications of COVID-19 in the nasal cavities and nasal function. CASE REPORT: We report the unique case of a young female patient, with a remote history of septoplasty and functional endoscopic sinus surgery who developed severe nasal airway obstruction (NAO) and saddle nose deformity two to three weeks after her recovery from COVID-19. CONCLUSION: This case report illustrates a late septoplasty complication that may be associated with COVID-19. This unusual clinical presentation indicates that structural destabilization of the nose may ensue as a complication of the COVID-19, and requires further investigation of the SARS-CoV-2 effects in vascularity and wound healing in the nasal cavity.

Although the effects of SARS-CoV-2 (COVID-19) infection in olfaction have been well established, there is relative paucity of information on possible other complications of in the nasal cavities and nasal function.

We report the unique case of a young female patient, with a remote history of septoplasty and functional endoscopic sinus surgery who developed severe nasal airway obstruction (NAO) and saddle nose deformity two to three weeks after her recovery from COVID-19.

This case report illustrates a late septoplasty complication that may be associated with COVID-19. This unusual clinical presentation indicates that structural destabilization of the nose may ensue as a complication of the COVID-19, and requires further investigation of the SARS-CoV-2 effects in vascularity and wound healing in the nasal cavity.

J o u r n a l P r e -p r o o f

The impact of SARS-Coronavirus 2 (COVID-19) in olfaction and gustatory function has been extensively studied and reviewed, starting early at the course of the pandemic [1] . It also established that the viral infection can lead to multi-system dysfunction and emerging evidence suggests that SARS-CoV-2-mediated endothelial injury is an important effector of the virus [2, 3] .

This case report illustrates an unusually late onset complication (saddle nose deformity) and nasal airway obstruction (NAO) in a young female patient with remote history of nasal surgery, immediately after her recovery with COVID-19. The clinical presentation described below is suspicious for virus induced direct vascular compromise of the nasal structure either with direct effect to its vascularity or through a potential infectious complication of the disease (e.g. undiagnosed septal abscess).

A 44-year-old female with unremarkable medical history presented to the senior author's practice complaining of recent onset external nasal deformity and complete nasal airway obstruction. She reported a remote history of uneventful septoplasty and limited functional endoscopic sinus surgery seven years prior to this presentation. She considered her nasal surgery successful and had no postoperative issues with her nasal form or function. Her current complains, were noticed two to three weeks after her recovery from COVID-19 disease which was diagnosed approximately two months prior to her presentation to our office. Her COVID-19 lasted approximately three weeks, was diagnosed with a nasal swab and did not require hospital admission. Approximately one week after her COVID-19 diagnosis, the patient visited the local emergency room complaining of severe nasal pain and nasal congestion. In this visit, the patient also reported severe edema and erythema in her nasal dorsum and bilateral periorbital area. The patient confirmed these complains during her visit to our office, in accordance with the records that we obtained from the emergency room. She was afebrile and J o u r n a l P r e -p r o o f with stable vital signs, and no further laboratory tests or imaging were ordered in the emergency room visit. She was treated with reassurance and an outpatient course of azithromycin.

The patient reports that she noticed the collapse of her nasal bridge approximately two to three weeks after her full recovery from COVID-19. She was electively referred to our facial plastic surgery practice by her primary care physician to explore her options with her cosmetic and functional concerns. The physical examination revealed severe saddle nose deformity (Fig. 1) and an "inverted V" deformity of the nasal pyramid (Fig. 2) , reflecting the collapse of the nasal framework. The septum had no obvious perforations, but the bilateral internal nasal valve narrowing was noticed, as well as obstruction of bilateral nasal cavities. The endoscopic examination confirmed these findings (Fig. 3) , and also revealed well healed bilateral maxillary antrostomies and partial ethmoidectomies without purulence or significant crusting. Her Nasal Obstruction and Septoplasty Effectiveness (NOSE) scale score (Fig. 4) completed routinely in the office was 100 (20/20). The patient was offered a nasal steroid spray, and we extensively discussed the surgical plan to address her functional and cosmetic concerns through an open septorhinoplasty approach, and possible need for auricular or rib cartilage graft harvesting. She decided to adhere to the nasal steroid trial and consider the surgical procedure in the near future at her convenience.

COVID-19 induced vasculopathy is a well-established characteristic of the disease with cardiologic, neurological and peripheral vascular manifestations [4] [5] [6] . The exact pathophysiologic mechanism of COVID-19 induced vasculopathy remains obscure, but a cytokine-induced endothelial destruction similar to the one produced by other viruses (influenza) has been theorized in the literature [7, 8] . Therefore, it can be hypothesized that COVID-19 can 

This case represents the first published report of nasal framework collapse and subsequent severe NAO associated with COVID-19, in line with the established vasculopathic effects of SARS-CoV-2. Our patient was young, without significant medical comorbidities and was satisfied with her nasal form and function after her initial septal surgery. The present report, illustrates the potential impact of COVID-19 in the nose, and emphasizes the need for a thorough physical examination and work up in a COVID-19 patient with acute nasal symptoms and signs. It also highlights the need for preoperative patient education during nasal surgery in the times of the pandemic. Finally, further research in the field of COVID-19 related impaired wound healing will be required. 

The Prevalence of Olfactory and Gustatory Dysfunction in COVID-19 Patients: A Systematic Review and Meta-analysis

COVID-19 -A vascular disease

SARS-CoV-2 cell entry receptor ACE2 mediated endothelial dysfunction leads to vascular thrombosis in COVID-19 patients

Cardiovascular Manifestations of COVID-19: Insights into a Single-Center Experience

Neurological Manifestations of COVID-19: A systematic review and current update

First, do no harm: bilateral radial artery occlusion in a COVID-19 patient

Description and Proposed Management of the Acute COVID-19 Cardiovascular Syndrome

The cytokine storms of COVID-19, H1N1 influenza, CRS and MAS compared. Can one sized treatment fit all?

Delayed Septal Perforation as a Complication of COVID-19: A Case Report

Classification and treatment of the saddle nose deformity

Complications in septoplasty based on a large group of 5639 patients